NUR 425 FINAL EXAM LATEST TEST BANK

pg. 1

NUR 425 FINAL EXAM LATEST / TEST BANK

|ACTUAL EXAM QUESTIONS WITH CORRECT

DETAILED ANSWERS (VERIFIED ANSWERS) AGRADE!!

Following norepinephrine (Levophed) administration, it is essential to the

nurse to assess:

• electrolyte status
• color and temperature of toes and fingers
• capillary refill
• ventricular arrhythmias - Correct Answer - B (Because decreased

perfusion is a side effect of norepinephrine (Levophed), the nurse must check circulation frequently. Capillary refill is not a reliable indication of perfusion in a shock state. Choices A and D are not specific for norepinephrine.)

When administering dopamine (Intropin), it is most important for the nurse

to know that:

• the drug's action varies according to the dose.
• the drug may be used instead of fluid replacement.
• the drug cannot be directly mixed in solutions containing bicarbonate or

aminophylline.

• the lowest dose to produce the desired effect should be used. - Correct

Answer - C (The nurse is responsible for knowing compatible solutions before administering dopamine (Intropin). It is important to know that drug action varies by dose, but the physician is responsible for determining the dose. Dopamine should not be used instead of fluid replacement. Choice D is incorrect because, although it is true, it is not the nurse's primary concern. It is a collaborative action in which the physician is involved in determining the rate.) 1 / 4

pg. 2

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 - Correct Answer - 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
• Stridor - Correct Answer - 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 - Correct Answer - A 2 / 4

pg. 3 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
• Septic - Correct Answer - C

You have just been given report on your patient in the ICU. You immediately go into your patient’s room to assess for pain. Which of the following would be indicative that the patient is in pain? Select all that apply.

• They are fighting the ventilator.
• Their limbs are bent.
• Their facial expression is relaxed.
• They are restless.
• Their muscles are relaxed. - Correct Answer - A B D

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 - Correct Answer - B (Decreased

RR would be indicative of a parasympathetic response. Increased RR would be indicative of pain.)

• / 4

pg. 4

True or False: Titrated analgesics should be included in the patient's I's and

O's. - Correct Answer - 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 - Correct

Answer - E (Always assess first!)

Which of the following patients would *not* need sedation?

• A 42-year-old male patient with a history of diabetes who has pulled out

his IV 3 times.

• A 10-year-old female who has just been admitted to the trauma bay with

3rd degree burns on 80% of her body.

• An 18-year-old male that is agitated from lack of sleep.
• A 30-year-old paralyzed male that cannot breathe independently upon

admittance to the ER. - Correct Answer - C

• / 4