NUR 425 EXAM 1ACTUAL EXAM -

NUR 425 EXAM 1(ACTUAL EXAM -

QUESTIONS AND ANSWERS.

Which of the following is NOT a likely sign of pain in a nonverbal patient?

• Eyes clenched shut when turning the patient
• Decreased respiratory rate
• Patient resists bending of her elbow when you try to

contract her arm

• Heart rate of 120 in a 54 year old male - Answers___B

(Decreased RR would be indicative of a parasympathetic response. Increased RR would be indicative of pain.) How are hemodynamics altered in hypovolemia? -

Answers___CVP: Low

PAWP: Low

CO/CI: Low

EF: Low

SV: Low

SVR: High (Due to vasoconstriction)

You are caring for a client in hypovolemic shock. Which of the follow manifestations would you expect to see in this type of shock?

• ARDS
• Sense of impending doom
• Flaccid paralysis 1 / 4

NUR 425 EXAM 1(ACTUAL EXAM -

QUESTIONS AND ANSWERS.

• Bronchoconstriction - Answers___B (B is correct because

patients can have a sense of impending doom during hypovolemic shock. ARDS is seen in late septic shock, which is when fluid collects in the lung air sacs. Flaccid paralysis is seen in neurogenic shock. Bronchoconstriction is seen in anaphylactic shock.)

You are caring for a client in hypovolemic shock. Which of the follow manifestations would you expect to see in this type of shock?

• Crackles
• Angioedema
• Jugular venous distention
• Tachypnea - Answers___D (Crackles is seen in cardiogenic

shock. Angioedema is seen in anaphylactic shock. JVD is seen in obstructive shock.)

You are caring for a client in cardiogenic shock. Which of the follow manifestations would you expect to see in this type of shock?

• Tachycardia
• Bladder and bowel dysfunction
• Sense of impending doom 2 / 4

NUR 425 EXAM 1(ACTUAL EXAM -

QUESTIONS AND ANSWERS.

• Stridor - Answers___A (In cardiogenic shock, there is

hypotension with tachycardia as well as signs of poor tissue perfusion. Bladder and bowel dysfunction is characteristic of neurogenic shock. A sense of impending doom is seen with hypovolemic shock. Stridor is seen with anaphylactic shock.)

Your patient comes into the emergency room and is diagnosed by the ER doctor with abdominal compartment syndrome.Which of the following types of shock would you watch for with this condition?

• Obstructive
• Neurogenic
• Cardiogenic
• Septic - Answers___A

A patient is admitted to the emergency room complaining of severe chest pain in their jaw, mid sternum area, and left arm.A 12-lead EKG is applied and the pattern shows ST elevation.Which of the following types of shock is the patient at risk for?

• Obstructive
• Neurogenic
• Cardiogenic 3 / 4

NUR 425 EXAM 1(ACTUAL EXAM -

QUESTIONS AND ANSWERS.

• Septic - Answers___C

True or False: Titrated analgesics should be included in the

patient's I's and O's. - Answers___True!

You walk into your intubated patient's room with an IV

fentanyl drip at 25mcg/hour who presents with the following:

Heart rate: 130

BP: 140/90

RR: 29

Which of the following should the nurse do first?

• Ask the patient to rank her pain on a scale of 0-10
• Increase the fentanyl drip rate per protocol
• Call the physician for additional pain medication orders
• Get a music therapy consult
• Look at the patient's facial expression and muscle tension -

Answers___E (Always assess first!)

You walk into your intubated patient's room with an IV

fentanyl drip at 25mcg/hour who presents with the following:

Heart rate: 130

BP: 140/90

RR: 29, ventilator alarming

• / 4