which medical surgical concepts has the highest priority when the patient develops shock?
perfusion
which statements about shock are true? select all that apply
a. shock is a whole body response to tissues not receiving enough oxygen
b.shock is widespread of normal cellular metabolism
c. shock may occur in older adults in response to urinary tract infections
d. shock affects all body organs
which hormones are released in response to decreased mean arterial pressure select all that apply
a. renin
b. ADH
c. epinephrine
d. aldosterone
which condition results in blood vessels that are normally partially constricted?
sympathetic tone
the patient has decreased oxygenation and impaired tissue perfusion. Which clinical manifestations are evidence of onset of the non-progressive or compensatory stages of shock?
a. decreased urine output
b. narrowing pulse pressure
c. increased heart rate
d. increase sodium absorption
which statement about the systemic effects of shock are correct?
tolerate hypoxia and anoxia up to 1 hour without permanent damage
which patients are at risk for shock related to fluid shifts? select all that apply
a. severely malnourished patient
b. patient with ascites
c. patient with kidney disease
d. patient with a large wound
a young woman comes to the emergency department with lightheadednessand a feeling of impending doom. pulses 110 beats per minute respirations are 30 a minute and blood pressure is 140/90. which factors does the nurse ask about that could contribute to sho
a. recent accident or trauma
b. prolonged diarrhea or vomiting
c. possibility of pregnancy
d. use of over-the-counter medications
which are specific causes or risk factors for cardiogenic shock? select all that apply
a. myocardial infarction
b. ventricular dysrhythmias
c. cardiomyopathy
which patient is at risk for obstructive shock?
patient with a pulmonary embolus
the patient has cardiac dysrhythmias and pulmonary problems as a result of receiving the first dose of a new IV antibiotic. The nurse recognizes that this represents what type of shock?
anaphylactic
a patient with a head trauma was treated for cerebral hematoma. after surgery, this patient is at risk for what type of shock?
neural - induced distributive
the nurse is performing a morning shift assessment on several patients. for which patient is the nurse immediately concerned about decreased tissue perfusion if the capillary refill time was delayed?
patient with severe dehydration
the nursing student takes the morning blood pressure of a post-operative patient, and the reading is 90/50. what does a student do next? select all that apply
a. report the reading to the primary nurse as a possible sign of hypovolemia
b. assess the patient for subjective feelings of dizziness or shortness of breath
c. check the patient's chart for trends in morning vital sign readings
d. notify the instructor
a patient at risk for shock has had some small, subtle changes in behavior within the past hour. how does the nurse evaluate the patient's mental status throughout the night?
periodically attempt to awaken the patient and document how easily he or she is aroused
for which indications would the nurse be prepared to administer a collide product? select all that apply
a. hemorrhagic shock
b. peripheral tissue hypoxia
c. restore osmotic pressure
d. increase hematocrit and hemoglobin levels
the patient at risk for hypovolemic shock tells the nurse that he is very thirsty. Which action should the nurse delegate to the unlicensed assistive personnel first?
check the patient's vital signs
which questions can help guide the nurse when evaluating the mental status of a patient at risk for shock? select all that apply
a. is it necessary to repeat questions to obtain a response?
b. does the response answer the question asked?
c. does the patient have difficulty making word choices?
d. is the patient irritated or upset by the questions?
e. how long is the patient's atten
a nurse is caring for a patient at risk for hypovolemic shock. what is the first sign of hypovolemic shock the nurse should monitor?
increasing heart rate
assessment findings of a patient with trauma injuries reveal cool and pale skin, reported thirst, urine output of 100 ml in 8 hours, blood pressure 122/78, pulse 102 beats per minute, and respirations 24 minute with decreased breath sounds. the nurse reco
non-progressive
a patient with blunt trauma to the abdomen has been NPO for several hours in preparation for a procedure and now reports thirst. what is the nurses priority action?
take the patient's vital signs and compare to baseline
a patient is brought to the emergency department with a gunshot wound. what are the early signs of hypovolemic shock the nurse should monitor? select all that apply
a. increase in heart rate
b. increase in respiratory rate
c. decreased map of 10 to 15 mmhg
the unlicensed assistive personnel reports repeatedly and unsuccessfully trying to take a patient's blood pressure with the electronic and manual devices. The nurse notes that the patient's apical pulse is elevated and the patient is at risk for hypovolem
apply the manual cuff and palpate for the systolic
the nurse identifies signs and symptoms of internal hemorrhage in a post-operative patient. what is included in the care of this patient for hypovolemic shock? select all that apply
a. elevate the feet with the head flat or elevated 30 degrees
b. monitor vital signs every 5 minutes until they are stable
c. provide oxygen therapy
d. ensure IV access
a young trauma patient is at risk for hypovolemic shock related to occult hemorrhage. what baseline indicator allows the nurse to recognize early signs of shock?
pulse rate
which statement about assessment of skin during shock is accurate?
for a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes
a patient in hypovolemic shock is receiving sodium nitroprusside to enhance myocardial perfusion. what is an important nursing assessment when administering this drug?
assess blood pressure at least every 15 minutes because systemic vasodilation can cause hypotension
a patient with hypovolemic shock is receiving an infusion of dopamine. Which nursing interventions are essential when a patient is receiving this drug? select all that apply
a. take the blood pressure at least every 15 minutes
b. monitor urine output every hour
c. assess the patient for chest pain
d. check the infusion site every 30 minutes for extravasation
e. ask a patient receiving this drug about headaches
a patient with hypokalemia is restless and anxious. The skin is cool and pale, pulse is thready at a rate of 135 beats per minute, blood pressure is 92/50, and respirations are 32 per minute. What actions must the nurse take? select all that apply
a. obtain a stat order for an IV normal saline bolus
b. check vital signs at least every 15 minutes
c. notify the rapid response team
d. administer supplemental oxygen
a patients showing early clinical manifestations of hypovolemic shock. The health care provider orders an arterial blood gas. Which ABG value does the nurse expect to see in hypovolemic shock?
decrease pH with decrease pao2 and increased paco2
the nurse finds a patient on the bathroom floor. There is a large amount of blood on the floor and the patients hospital gown. Which actions must the nurse take? select all that apply
a. elevate the patient's legs
b. establish large-bore IV access
c. look for the source of the bleeding
d. ensure a patent airway
e. apply direct pressure to the bleeding site if possible
the nurse is caring for a post-operative patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock?
a rapid, weak, thready pulse
which IV therapy results in the greatest increase in oxygen carrying capacity for a patient with hypovolemic shock?
packed red cells
a patient comes to the emergency department with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid?
0.9% sodium chloride
which change in the skin is an early indication of hypovolemic shock?
pallor or cyanosis in the mucous membranes
a patient is in hypovolemic shock related to hemorrhage from a large gunshot wound. Which order must the nurse question?
give furosemide (LASIX) lasix 20 mg slow IVP
the nurse is performing a psychosocial assessment on a patient who is at risk for shock. Which statement made by the patient is of greatest concern to the nurse?
something feels wrong, but I'm not sure what is causing me to feel this way
a patient at risk for hypovolemic shock has a central venous pressure catheter in place. Which finding is a priority concern for the nurse?
central venous pressure is decreased from 6 to 1 mm Hg
a patient is being discharged from the same day surgery unit to home. Which early indicators of shock will the nurse teach the patient and family member to watch for and to seek medical attention immediately if they occur? select all that apply
a. decreased urine output
b. lightheadedness
c. sense of apprehension
a patient has a systemic infection with a fever, increased respiratory rate, and change in mental status. Which laboratory values does the nurse seek out that are considered "hallmarks" of sepsis?
increased serum lactate level and rising band neutrophils
the nurse is caring for an older adult patient at risk for shock. what is an early sign of shock in this patient?
restlessness
the nurse is caring for a patient with sepsis. at the beginning of the shift, the patient is in a hyperdynamic state. several hours later, the patient has a rapid respiratory rate, decreased urine output, and altered level of consciousness. how does the n
worsening of the condition rather than improvement
the nurse is caring for a patient with sepsis. what is a late clinical manifestation of shock?
decrease in blood pressure
the nurse is caring for a patient at risk for sepsis. why does the nurse closely monitor the patient for early signs of shock?
prevention of septic shock is easier to achieve in the early phase
a patient has a localized infection. what assessment findings are considered evidence of a beneficial inflammatory response?
redness and edema that subside in several days
the student nurse is assessing a patient's mental status because of the patient's risk for decreased tissue perfusion. The supervising nurse intervenes when the student nurse asks the patient which question?
is your name mr. John Smith?
a nurse is caring for a patient at risk for septic shock from a wound infection. to prevent systemic inflammatory response syndrome, the nurses priority is to monitor which factor?
localized infected area
the nurse is evaluating the care and treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment?
increased urinary output
the nurse is caring for a patient with septic shock. which therapy specific to the management of septic shock for this patient does the nurse anticipate will be used?
antibiotics
a patient receives dopamine 20 mcg/kg/minute IV for the treatment of shock. what does the nurse assess for while administering this drug?
chest pain and hypertension
which laboratory value indicates the beginning of severe sepsis even before other symptoms are evident?
decrease the level of activated protein C
the nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations are markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition?
metabolic acidosis
the ICU nurse observes petechiae, ecchymoses, and blood oozing from gums and other mucous membranes of a patient with septic shock. how does the nurse interpret this finding?
disseminated intravascular coagulation (DIC)
the nurse is reviewing the laboratory results of a patient with a systemic infection. what is the significance of a left shift in the differential leukocyte count?
indication that the infection is outpacing the white cell production
the ICU nurse is caring for a patient with septic shock. Which IV infusion order for this patient does the nurse question?
10% dextrose in water
the nurse is preparing a teaching session for a patient at risk for septic shock. Which topics does the nurse include in this teaching? select all that apply
a. wash hands frequently using antimicrobial soap
b. avoid large crowds or gatherings where people might be ill
c. do not share eating utensils
d. wash toothbrushes in a dishwasher
a patient is at risk for sepsis. Which assessment finding is most indicative of the hyperdynamic activity that occurs in septic shock?
increase pulse rate with warm, pink skin
the home health nurse is visiting a frail older adult patient at risk for sepsis because of failure to thrive and immunosuppression. what does the nurse assess this patient for? select all that apply
a. signs of skin breakdown in presence of redness or swelling
b. cough or any other symptoms of a cold or the flu
c. appearance and odor of urine, and pain or burning during urination
d. availability and type of facilities for hand washing
e. general clea
a post-operative hospitalized patient has a decreased in mean arterial pressure of greater than 20 mm hg from baseline value; elevated, thready pulse; decrease blood pressure; shallow respirations of 26/minute; pale skin; and moderate hyperkalemia. the nu
progressive
a 70 year old man is admitted to the hospital with an infected finger for several days duration. he is lethargic and confused and has a temperature of 101.3 degrees. other assessment findings include a blood pressure of 94/50 mmhg, pulse 105 beats/min, re
septic
the clinical manifestations in the first phase of sepsis induced distributive shock result from the body's reaction to what factor?
infectious microorganisms
which factor increases in older adults risk for distributed (septic) shock?
reduce skin integrity
which patients are at risk for distributive (septic) shock? select all that apply
a. older adult with urinary tract infection
b. patient with pneumonia
c. older adult with sacral pressure ulcers
the nurse is caring for a patient in septic shock with a serum glucose level of 280 mg/dL. what is the nurses best interpretation of this finding?
this finding is associated with a poor outcome
patient has been diagnosed with sepsis. following the sepsis resuscitation bundle, which intervention should the nurse expect within the first 3 hours? select all that apply
a. obtain serum lactate level
b. draw blood cultures
c. administer broad-spectrum antibiotics
the unlicensed assistive personnel working under supervision of an RN is checking vital signs on the patient at risk for hypovolemic shock. Which instruction must the nurse give the UAP?
report any increase in heart rate because it is an early sign of shock
the nurse is assessing a patient who is newly diagnosed with anemia. Which assessment findings are typical of this disorder? select all that apply
a. dyspnea on exertion
b. concave appearance of nails
c. pallor of the ears
d. headache
which activities are performed by infusion nurses? select all that apply
a. develop evidence-based policies and procedures
b. insert and maintain peripheral and central venous catheters
c. consult on product selection and purchasing decisions
d. monitor patient outcomes of infusion therapy
e. provide education to staff, patien
the nurse is preparing to start an infusion of dextrose 10% in water. why would the nurse reviews the solutions through a central line?
osmolarity of the solution could cause phlebitis or thrombosis
intravenous therapy with a hypotonic fluid is ordered for the patient. The nurse would plan to start which solution?
0.45% NaCl
a patient with lung cancer is to receive his first chemotherapy treatment. Which IV access methods are appropriate for this patient? select all that apply
a. peripherally inserted Central catheter (PICC)
b. tunneled central venous catheter
c. implanted port
a patient has a peripherally inserted Central catheter placed and received IV cisplatin. the drug has infiltrated into the tissue, and redness is observed in the right lower side of the neck. what is the nurses first action?
stop the infusion and disconnect the IV line from the administration set
the nurse is preparing to give a patient IV drug therapy. what information does the nurse need before administering the drug? select all that apply
a. indications, contradictions, and precautions for IV therapy
b. appropriate dilution, pH, and osmolarity of solution
c. rate of infusion and dosage of drugs
d. compatibility with other IV medications
e. parameters to monitor related to immediate drug ef
the charge nurse is reviewing IV therapy orders. what information must be included in each order? select all that apply
a. specific type of solution
b. rate of administration
c. specific drug dose to be added to the solution
d. frequency of drug administration
the nurse must insert a short peripheral IV catheter. to decrease the risk of deep vein thrombosis or phlebitis, which area of the arm should be chosen for insertion of the IV catheter?
forearm
a patient requires IV therapy via a peripheral line. what factors does the nurse consider when inserting the peripheral IV? select all that apply
a. for active adults, start with more proximal sites such as the forearm
b. choose the patient's non-dominant arm
c. do not use the arm at the patient had a mastectomy on that side
d. avoid placing an IV on the anterior surface of the wrist
assessing a patient's IV site, the nurse identifies signs and symptoms of infiltration. what is the first action that the nurse implements for this patient?
stop the IV infusion
after completing the insertion of the peripherally inserted Central catheter, what does the nurse put in the documentation? select all that apply
a. type of dressing applied
b. type of IV access device used
c. vein that was used for insertion
d. length of catheter, the insertion site, and tip location
the nurse is selecting a site for peripheral IV insertion. Which patient condition influences the choice of left vs right upper extremity?
regular renal dialysis with a shunt in the left upper forearm
the nurse is attempting to insert a peripheral IV when the patient reports tingling and a feeling like pins and needles. what does the nurse do next?
stop immediately, remove the catheter, and choose a new site
a patient has been on prolonged steroid therapy. In assessing the patient for an IV insertion site, what finding does the nurse expect to see?
ecchymosis and possibly a hematoma
under what circumstance does the nurse select to use one secondary set to administer multiple medications instead of a secondary set to administer each medication?
when the medications are compatible
when using an intermittent administration set to deliver medications, how often does the infusion nurses society recommend that the set be changed?
every 24 hours
the nurse is supervising a student nurse who is preparing an IV bag with IV administration tubing. for which action by the student nurse must the nurse intervene?
the student touches the tubing Spike
the nurse is caring for a patient with a PICC line. according to recommendations by the infusion nurses society which technique does the nurse use in maintaining this type of catheter?
use 10 mL of sterile saline to flush before and after medication
a patient has a PICC placed by an IV therapy nurse at the bedside. before using the catheter, how is its placement verified?
a chest x-ray is taken, which shows the catheter tip in the lower superior vena cava
a patient requires a nontunneled percutaneous Central catheter. what is the nurse's role in this procedure?
place the patient in Trendelenburg position
a patient requires an infusion of packed red blood cells. Which factor allows the nurse to infuse the packed red blood cells through the patient's peripherally inserted Central catheter?
lumen size of the PICC is 4 FR or larger
which patient is the most likely candidate for a tunneled central venous catheter?
patient in need of permanent parenteral nutrition
which nursing interventions are implemented when caring for a patient with an implanted Port? select all that apply
a. before puncture, palpate the port to locate the septum
b. flush the port before each use
c. use a non coring needle to access the port
d. check my blood returned before giving any drug through a port
a 65 year old patient has been receiving IV D5 1/2 NS at 100 ml an hour for the past three days, along with IV antibiotic therapy. The patient reports chills and a headache. on assessment, the patient's temperature is elevated. what complication do these
catheter-related infection in the blood
which disadvantage accompanies the placement of a large bore peripheral IV catheter?
increased occurrence of phlebitis
what is the minimum size peripheral IV catheter through which a blood transfusion can be infused?
22 gauge
a patient has a central line inserted in the vena cava. The nurse assesses the patient for which potential complications related to the procedure? select all that apply
a. hemothorax
b. air embolism
c. bloodstream infection
the nurse is assessing a patient's vascular access for phlebitis. The IV site shows erythema with swelling and pain. based on infusion nurses society standards, which grade of phlebitis would the nurse document?
grade 2
a triple lumen catheter central line is inserted in a patient what does the nurse do immediately after the procedure?
obtain a portable chest x-ray and hold IV fluids until results are obtained
when providing care for an older patient receiving IV fluids through a central line at a hundred 50 ml an hour, the nurse finds the patient has shortness of breath, cough, puffiness around the eyes, and crackles. what does the nurse do next?
place the patient in an upright position, administer oxygen, slow IV rate, and notified the care provider
which interventions by the staff nurse are essential to prevent an infection in a patient with a central line? select all that apply
a. assess the dressing and insertion site of the central line
b. employee aseptic technique when administering medications and changing tubing
c. use sterile technique when assisting the hcp with insertion of the central line
d. use proper hand washing an
a patient with an implanted Port is discharged home to receive long-term therapy on an outpatient basis. how frequently must the implanted Port be flushed between courses of therapy?
monthly
the nurse is preparing to deliver IV infusion therapy through an implanted Port. what technique does the nurse use to access the port?
palpate the port, scrub skin, and access with a non coring (Huber) needle
a patient is to be discharged home with an implanted port and needs discharge instructions on prescribed medication administration. Which instructions must the nurse give to the patient and family member who will be assisting the patient? select all that
a. the skin will be punctured over the port when the port is accessed
b. when the port is not access, no dressing needs to be applied
c. the port must be flushed after each use
the nurse is preparing to administer IV infusion therapy to a patient. when is the choice of using a glass container appropriate?
when the drug is incompatible with a plastic container
a patient requires a 2-month course of IV antibiotics to treat a resistant infection. Which device is chosen for this therapy
PICC
the nurse is attaching an administration set to the central venous catheter. Which type of equipment increases the risk of accidental disconnection or leakage?
Luer- Lok connector
the nurse is adding a filter to an IV administration set up. where is the best place to add the filter to the IV line?
as close as possible to the catheter hub
which safety measures does the nurse apply to decrease the risk of catheter-related bloodstream infection related to needless systems? select all that apply
a. tape connections between tubing sets
b. clean all needleless connections vigorously for at least 60 seconds before connecting
c. use evidence-based hand-hygiene guidelines from the CDC and OSHA
a patient is receiving IV therapy via an infusion pump. what is the priority nursing responsibility related to the equipment?
ensure the IV pump is programmed correctly
which characteristics apply to IV infusion pumps? select all that apply
a. deliver fluids under pressure
b. can be pole mounted or ambulatory and portable
c. are best for accurate infusion
d. decrease drug errors through smart technology
which content must the nurse be sure to teach a patient before central line insertion, specific to prevention of catheter related bloodstream infection? select all that apply
a. the type of catheter used
b. hand hygiene and aseptic technique for care of the catheter
c. activity limitations
d. signs and symptoms of complications
the nurse is assessing a patient's IV insertion site. what must the nurse look for during the assessment? select all that apply
a. observe for redness and swelling
b. check that the dressing is clean and dry
c. observe for yellow discoloration
d. observe for hardness or drainage
a patient's central venous IV site is covered with a transparent membrane dressing. how often does the nurse change this dressing?
every 5 to 7 days
a patient is ordered to receive peripheral parenteral nutrition. what type of access device is appropriate for this patient?
PICC
an external long-term IV catheter is required for hemodialysis of a hospitalized patient. Which statements are true about this external long-term IV access device? select all that apply
a. should not be used for administration of other fluids are medications except in an emergency
b. is required for hemodialysis because it has a large lumen
c. can often cause a common problem of venous thrombosis
d. is a tunneled catheter with large lume
the nurse has removed the dressing from a patient's central venous catheter site. to monitor the catheter position, what does the nurse do?
note the length of the catheter external to the insertion site
the nurse is caring for a patient with a central venous catheter. when changing the administration set or connectors, what measures will the nurse use to prevent air emboli? select all that apply
a. position the patient flat so the catheter site is below the heart
b. uses the pinch clamp that can be closed during the procedure
c. ask the patient to perform the valsalva maneuver by holding the breath and bearing down
d. time the IV set change to th
after assessing the patency of a patient's IV catheter, the nurse attempts to flush the catheter and meets resistance. what does the nurse do next?
stop the flush attempt and discontinue the IV
the nurse is flushing a patient's short peripheral IV catheter. what solution and volume does the nurse typically use for this procedure?
3 ml of normal saline
the patient is ready for discharge. Which actions must the nurse follow to remove the patient's peripheral catheter? select all that apply
a. hold pressure on the site until hemostasis is achieved
b. assess the catheter tip to make sure is intact and completely removed
c. remove the peripheral catheter dressing
d. document catheter removal and the appearance of the IV site
well attempting to remove a PICC line, the nurse feels resistance. what technique does the nurse use first to attempt to resolve this problem?
use simple distraction techniques and deep breathing
the nurse is assessing a short peripheral catheter after removal, and it appears that the catheter tip is missing. what does the nurse do next?
assess the patient for symptoms of emboli
which instruction does the nurse give to an unlicensed assistive personnel who has been delegated to check blood pressure on six patients being infused with peripheral IV fluids?
do the blood pressure checks on the arm that doesn't have the IV fluids infusing
a patient has a local complication from a peripheral IV access with 0.9% normal saline and infusing at a hundred mL/hr. what does the nurse assess at the insertion site? select all that apply
a. a red streak is present proximal to the site
b. edema is present proximal to the site
c. the IV fluids are not infusing
d. the patient reports numbness and tingling at the site
the nurse is caring for a patient receiving arterial therapy via the carotid artery. what important nursing action is specific to this therapy?
perform frequent neurologic assessments
which statements are correct about intraperitoneal infusions? select all that apply
a. IP can be accomplished by a catheter with an implanted port and large internal lumens
b. strict aseptic technique is used with IP access and supplies
c. IP is used for patients who are receiving chemotherapy agents
during intra-peritoneal therapy, a patient reports nausea and vomiting. what does the nurse do next?
reduce the flow rate and give antiemetics
in what position does the nurse place a patient before starting intraperitoneal therapy?
semi Fowler's
which task would the nurse delegate to a UAP for a patient receiving intraperitoneal therapy?
assist the patient to move from side to side to distribute fluid evenly
hypodermoclysis can be used for a patient under which types of circumstances? select all that apply
a. if the patient requires palliative care
b. for IV fluid replacement that is less than 2000 mL
c. when a subcutaneous IV infusion is warranted
d. when short-term fluid volume replacement is warranted
the nurse is preparing to start a hypodermoclysis treatment on a patient. what is a preferred insertion site?
area under the clavicle
the home health nurse is adjusting the rate for a hypodermoclysis treatment. what is the usual maximum rate for this therapy?
120 mL/hr
the home health nurse is caring for a patient receiving hypodermoclysis therapy. how often are the subcutaneous sites rotated?
at least once a week
which illnesses can be treated by an intrathecal infusion? select all that apply
a. cancer of the central nervous system
b. reflex sympathetic dystrophy
c. multiple sclerosis
d. anoxic acquired brain injury
a patient is receiving epidural medication therapy. The nurse assesses for which potential problem specific to this type of therapy?
meningitis
is brought to the emergency department after a serious motor vehicle accident. Which factor makes the patient a candidate for intraosseous therapy?
IV access cannot be achieved within a few minutes (emergency)
a patient has an intraosseous needle in place. why does the nurse advocate for the removal of the device within 24 hours after insertion?
there is an increased risk of osteomyelitis
the patient has an order for one unit of packed red blood cells. Which priority action must the nurse complete before starting this infusion?
check patient identification with another RN using two identifiers
which site is most commonly used for intraosseous therapy?
proximal tibia
the patient has an order for 0.45% normal saline 1000 ml to infuse over 15 hours. at what rate in milliliters would the nurse set the infusion pump?
67 mL/hr
which priority concept is of concern to the nurse when performing infusion therapy?
fluid and electrolyte balance
the nurse is performing a physical assessment on an adult with no known health problems. Which assessment finding poses the greatest Potential threat to the patient's immune system?
has poor oral hygiene and numerous Dental caries
which patients have factors that may affect the function of the immune system? select all that apply
a. patient has been on a severely limited diet
b. patient is homeless and is continuously seeking shelter for cold weather conditions
c. patient is on multiple medications, including corticosteroids and a non-steroidal anti-inflammatory
d. patient is 84 y
based on the nurses knowledge of the concept of immunity, what is an example of self tolerance?
skin from the patient's thigh it successfully grafted to a burn wound
production of immune cells will be most jeopardize by which event?
patient develops a bone marrow disorder
which person is most likely to be immuno competent?
45 year old female who works daily in her garden and eats a vegetarian diet
a patient has sustained a severe right ankle sprain, and the nurse is explaining the process of inflammation to the patient and family. Which information does the nurse include in this teaching?
symptoms of inflammation depend on the intensity and severity of the injury
which circumstance poses the greatest risk to good healthy exposure to living organisms?
infant children in a daycare play together and share toys and food
the actions of leukocytes provide the body protection against invading organisms. what are actions of leukocytes? select all that apply
a. phagocytic destruction of foreign Invaders and unhealthy or abnormal cells
b. lytic destruction of foreign Invaders and unhealthy cells
d. production of antibodies directed against Invaders
which patient would benefit most from receiving a detailed explanation about human leukocyte antigens?
patient has an identical twin who needs a kidney transplant
in which conditions is the inflammatory response present? select all that apply
a. sprain injuries to joints
b. appendicitis
c. myocardial infarction
d. contact dermatitis
e. allergic rhinitis
which cell types associated with the inflammatory response participate in phagocytosis?
macrophages and neutrophils
which type of white blood cell does the body produce most?
neutrophils
the nurse is reviewing the patient's laboratory results and see that there is a left shift (bandemia). which assessment is the nurse most likely to perform?
look for signs of infection and check temperature and pulse
what is the significance of toll-like receptors and helping the body to fight infection?
tlrs interact with the surface of an organism and allow recognition of non-self
when an injury or invasion occurs, phagocytosis involves seven steps. degradation is the final 7th step. place the first six steps that precede degradation in the correct order...
1. exposure and invasion
2. attraction
3. adherence
4. recognition
5. cellular ingestion
6. phagosome formation
7. degradation
what feature of stem cells has made them valuable to research and therapy?
pluripotency
the nurse assesses a patient who sustained a scalding burn to the left dorsal surface of the hands and figures that occurred one day ago. there is redness, swelling, and warm. The patient has pain, decreased fine motor movements, and limited range of moti
cardinal signs of inflammation
the nurse is caring for a patient prescribed a new oral antibiotic. eosinophils and basophils levels are elevated. what is the nurses best interpretation of this laboratory report?
the patient may be having an allergic reaction to the antibiotic
the patient's leg wound has increased blood flow (hyperemia) and swelling. The nurse recognizes this as stage 1 in the sequence of inflammation process. what would be considered a normal outcome for the stage?
symptoms usually subside within 24 to 72 hours
the patient reports a sore throat. The nurse notes that the throat is red and the tissues look swollen and inflamed. based on the concepts of general immunity and inflammatory response, what should the nurse tell the patient about immune protection?
protection is immediate but short-term and does not provide true immunity
the patient is receiving erythropoietin. If therapy is successful incorrectly stimulating stem cells, which laboratory results would the nurse expect to see?
increase in erythrocytes
which type of infection is most likely to result in a left shift (bandemia) that indicates an increased number of immature neutrophils?
bacterial infection
in which conditions might the nurse observe inflammation without infection? select all that apply
a. joint sprains
b. myocardial infarction
c. blister formation
d. allergic rhinitis
e. contact dermatitis
what is the clinical significance of the absolute neutrophil count?
the higher the number of matter circulating neutrophils, the greater the resistance to infection
which cells interact in the presence of an antigen to start antibody production? select all that apply
a. B-lymphocytes
b. macrophages
c. t helper - inducer cells
What things are most likely to manifest in a patient who is experiencing the release of histamine and kinins by basophils?
swelling and edema
in what way is antibody mediated immunity different from cell mediated immunity?
AMI can be transferred from one person to another CMI cannot
what is an example of the clinical significance of the anamnestic response?
person who had childhood measles is re-exposed as an adult but does not develop measles
what is an example of innate native immunity?
nurse has intact healthy skin on hands and healthy mucous membranes
an older resident living in a long-term care facility ask for help to go to the bathroom more frequently than usual. The nurse suspects a urinary tract infection. what changes in the immune system of an older adult should the nurse keep in mind? select al
a. older adults are more at risk for bacterial and fungal infections in the genitourinary tract
b. older adults may have an infection but not show expected changes in white blood cell count
c. older adults may not have a fever during inflammatory or infec
why do older adults have an increased risk for autoimmune diseases?
there is loss of recognition of self and an increase in circulating Auto antibodies
an older patient reports that he has been treated for tuberculosis in the distant past. he currently has a negative tuberculosis skin test. how does the nurse interpret the test results?
in older patients, false negative tuberculosis results are a possibility
a nurse is exposed to a viral infection at work. after several days, the nurse fully recovers and returns to work. what is the role of the memory cell in relation to the nurse is viral illness?
when the nurse is re-exposed to the same antigen, the memory cell will produce antibodies
a patient who is in good health is naturally assisted in cancer prevention by which type of immunity?
cell mediated
a babysitter is caring for a child who is in the pre-symptomatic stage of influenza a. The babysitter has never had influenza a and develop symptoms several days after care for the child. what type of immunity will the babysitter have as a result of antib
B cells will be sensitized only to influenza A
the action of which cell types must be suppressed to prevent acute rejection of transplanted organ select all that apply
a. cytotoxic - cytolytic t cells
b. natural killer cells
a patient is admitted with pneumonia and has developed sepsis. what can the findings from a differential white blood cell count reveal about this patient?
weather an infection is bacterial or viral
experienced a myocardial infarction six months ago during which 25% of his left ventricle was damaged and replaced by scar tissue. Which is the most likely outcome?
the patient will lose 25% of the effectiveness of his left ventricular contraction
a patient is admitted with a vascular problem. based on the pathophysiology of systemic arterial pressure, the systemic arterial pressure is a product of what factors? select all that apply
a. cardiac output
b. total peripheral vascular resistance
a patient with peripheral arterial disease is scheduled to have percutaneous transluminal intervention. what information does the nurse give the patient about this procedure?
reclusion may occur afterwards and the procedure may be repeated
a patient has returned to the unit after having percutaneous transluminal intervention. what nursing actions are included in the routine post-procedural care of this patient? select all that apply
a. observe for bleeding at the puncture site
b. observe vital signs frequently
c. perform frequent checks of the distal pulses in both limbs
d. administer antiplatelet therapy as ordered
a patient with an acute arterial occlusion requires abciximab. what nursing responsibilities are associated with the administration of this medication?
platelet counts must be monitored at 3, 6, and 12 hours after the start of the infusion
which statements are accurate about true aneurysm select all that apply
a. permanent dilation of an artery
b. enlarged artery to at least two times the normal diameter
c. arterial wall is congenitally weekend
d. aneurysms can be described as false aneurysms or true aneurysms
the nurse is reviewing a patient's abdominal CT scan and notes that the patient has an out pouch segment coming off of the abdominal aorta. what is the nurses best interpretation of these results?
saccular aneurysm
what is the most common location for an aneurysm?
abdominal aorta
what is the most common cause of an aneurysm?
atherosclerosis and hypertension
a patient is suspected to have an abdominal aortic aneurysm. what does the nurse assess for?
abdominal, flank, or back pain
a 75 year old man with a history of atherosclerosis comes to the emergency department with abdominal pain. what findings indicate possible abdominal aortic aneurysm? select all that apply
a. abdominal, flank, or back pain
b. visible pulsation of the upper abdominal wall
c. an abdominal bruit on auscultation
a patient with a abdominal aortic aneurysm is admitted to the hospital. Which test is the healthcare provider order to confirm an accurate diagnosis as well as to determine the size and location of the AAA? select all that apply
a. ultrasound
b. computed tomography
a patient is diagnosed with a 3 centimeter abdominal aortic aneurysm. what is the best non surgical intervention to decrease the risk of rupture of an aneurysm and a slow the rate of enlargement?
maintenance of normal blood pressure and avoidance of hypertension
a patient with a ruptured aneurysm May exhibit which symptoms? select all that apply
a. tachycardia
b. decrease blood pressure
c. severe pain
d. decreased level of consciousness
a patient has an abdominal aortic aneurysm that is small and asymptomatic. what priority teaching must the nurse complete that this patient?
you will have frequency CT scans or ultrasounds to monitor the growth of the aneurysm
a patient was admitted for an abdominal aortic aneurysm with a pulsating abdominal Mass. The nurse notes a sudden onset of diaphoresis, decreased level of consciousness, a blood pressure of 88/ 60 mmhg, and in a regular apical pulse. Oxygen is in place vi
alert the rapid response team
a patient is admitted through the emergency department for emergency surgery of a ruptured aneurysm. why does the nurse monitor the patient for renal failure?
hypovolemia associated with rupture can result in decreased urinary output
a patient is admitted to the hospital with deep vein thrombosis. Which drugs are preferred for treatment and prevention of DVT?
subcutaneous low-molecular-weight heparins
the patients with which conditions are candidates for an inferior vena cava filter placement?
a. recurrent deep vein thrombosis
b. no response to medical treatment
c. intolerance to anticoagulation drug therapy
d. recurrent pulmonary emboli
what is the recommended therapeutic range for the international normalized ratio (INR) for a patient receiving warfarin sodium?
1.5-2.0
a patient prescribed warfarin sodium is instructed that certain foods decrease the effect of the drug. Which foods if he in must be consumed in consistent and small amounts each day?
spinach and asparagus
the nurse is teaching a patient who is at risk for venous thromboembolism VTE. The patient is currently asymptomatic and is living in the community. what intervention does the nurse instruct the patient to do to minimize the risk of VTE? select all that a
a. avoid oral contraceptives
b. drink adequate fluids to avoid dehydration
c. exercise the legs during long periods of bed rest or sitting
d. avoid potential trauma such as contact sports
the nurse is reviewing the diagnostic test results for a patient suspected of having a deep vein thrombosis DVT. The results show a negative d-dimer test. how does the nurse interpret this data?
the test can exclude DVT without an ultrasound
the health care provider has ordered unfractionated Heparin for a patient with a deep vein thrombosis DVT. before administering the drug, the nurse ensures that which laboratory test for obtained for baseline measurement? select all that apply
a. prothrombin time PT
b. activated partial thromboplastin time aptt
c. international normalized ratio INR
d. complete blood count CBC with platelet count
e. urinalysis
the nurse notes that the platelet count for a patient who is to receive unfractionated Heparin is 100,000/mm3. how does the nurse interpret this result?
it is significantly low, so the healthcare provider should be notified
the medication order for unfractionated Heparin is 480 units/kg of body weight. how does the nurse interpret this order?
appropriate dose for the initial IV bolus
a patient is receiving anticoagulant therapy. The nurse instructs the unlicensed assistive personnel in which tasks related to the anticoagulant therapy?
watch for and report blood in the stool when assisting the patient with toileting
a patient received unfractionated Heparin therapy is order to discontinue the therapy and begin low-molecular-weight Heparin with enoxaparin. what is the priority nursing intervention?
discontinue the heparin at least 30 minutes before the first lmwh injection
Which novel oral anticoagulant drug currently has an antidote?
dabigatran
the nurse is teaching a patient about the side effects and potential problems associated with taking warfarin sodium. Which statement by the patient indicates a correct understanding of the nurses instruction?
for injury and bleeding, I should apply direct pressure and seek medical assistance
a patient with a venous stasis ulcer is prescribed the topical agent Acuzyme. what are the purposes of this drug? select all that apply
a. promote healing
b. chemically debride the ulcer
c. eliminate necrotic tissue
the nurse is instructing a patient and caregiver on warfarin (Coumadin) therapy at home. Which items does the nurse include in the teaching plan? select all that apply
a. eat small amounts of broccoli and spinach
b. inform your dentist of taking warfarin prior to treatment
c. avoid NSAIDs and birth control pills
d. be sure to have your INR lab checked as ordered
a patient has a venous stasis ulcer that requires a dressing. Which dressing materials are selected for this type of problem? select all that apply
a. oxygen permeable polyethylene film
b. oxygen impermeable hydrocolloid dressing
c. artificial skin products
d. unna boot
the nurse is assessing the IV site of a patient who has been receiving a normal saline infusion. there is redness and warmth radiating up the arm with pain, soreness, and swelling. what does the nurse do next?
discontinue the IV and apply warm, moist soaks
which patient has the greatest risk for a pulmonary embolus related to a venous disorder?
patient with thrombophlebitis in a deep vein of the lower extremity
the nurse observes diminished pulses, cold skin, and a pulsatile mass over the femoral artery in a patient reporting pain in the right leg. what condition does the nurse suspect in this patient?
femoral aneurysm
the nurse is providing care for a patient with venous insufficiency. Which medical surgical concepts have priority with this patient? select all that apply
a. perfusion
b. clotting