Nokea
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?
- A. Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
- B. A white blood cell count of 18,000/mm3.
- C. A urinary output of 90 mL in the last four (4) hours.
- D. The client complains of being thirsty.
Correct Answer: C
Rationale: Urinary output of 90 mL/4 hours = 22.5 mL/hour, below 30 mL/hour, indicating renal hypoperfusion, requiring immediate intervention. Fever, tachycardia, and elevated WBC are expected; thirst is less urgent.
You may also like to solve these questions
The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation?
- A. Contaminated water is the only source of transmission of biological agents.
- B. Vaccines are available and being prepared to counteract biological agents.
- C. Biological weapons are less of a threat than chemical agents.
- D. Biological weapons are easily obtained and result in significant mortality.
Correct Answer: D
Rationale: Biological weapons are easily obtained (e.g., anthrax) and cause high mortality, making them a significant threat. Water is not the only transmission route, vaccines are limited, and biological threats rival chemical ones.
The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time?
- A. Child Protective Services (CPS).
- B. The local police department.
- C. The Department of Health.
- D. The Poison Control Center.
Correct Answer: D
Rationale: The Poison Control Center provides immediate guidance on ingested toxins, critical for treatment. CPS, police, and health departments are secondary.
A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?
- A. Hold their breath as much as possible.
- B. Stand up to avoid heavy exposure.
- C. Lie down to stay under the exposure.
- D. Attempt to breathe through their clothing.
Correct Answer: C
Rationale: Lying down minimizes exposure to chemical agents, which may settle lower. Breath-holding is temporary, standing increases exposure, and clothing is minimally protective.
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?
- A. Cardiogenic shock.
- B. Hypovolemic shock.
- C. Neurogenic shock.
- D. Septic shock.
Correct Answer: B
Rationale: NSAID-induced gastrointestinal bleeding can cause hypovolemic shock, indicated by tachycardia, hypotension, and pale, clammy skin. Cardiogenic involves cardiac failure, neurogenic involves bradycardia, and septic involves fever.
The nurse is caring for a client in the ED with abdominal trauma who has had peritoneal lavage. Which intervention should the nurse include in the plan of care?
- A. Assess for the presence of blood, bile, or feces.
- B. Palpate the client for bilateral femoral pulses.
- C. Perform Leopold’s maneuver every eight (8) hours.
- D. Collect information on the client’s dietary history.
Correct Answer: A
Rationale: Peritoneal lavage detects blood, bile, or feces, indicating internal injury. Femoral pulses, Leopold’s maneuver (pregnancy), and diet history are irrelevant.