[Expert Solution]: A nurse is caring for a client with…

A nurse is caring for a client with neurogenic shock. The nurse knows which of the following symptoms would be the hallmark symptom of neurogenic shock? Answers: A – D A Hypotension B Bradycardia C Tachycardia D Hypertension A nurse is taking care of a client s/p motor vehicle accident ( MVA) with a severe brain injury. The client’s GSC is 3 and the client is posturing. The nurse understands that which type of posturing would indicate the most severe and deepest brain injury? Answers: A -D A Decerebrate posturing B Decomposed posturing C Decompensated posturing D Decorticate posturing A nurse is caring for a client with acute Disseminated intravascular Coagulation (DIC) in the ICU. The nurse knows that DIC is definitively diagnosed by which of the following test results. Answers: A – D A Increased PT/aPTT levels B None of the above C Increased coagulation factors D Decreased D dimer The nurse is caring for a bed bound client with sepsis and a fluid volume deficit in the ICU. The client has a history of urinary tract infections (UTI’s) and urinary retention. The client is currently incontinent of both bowel and bladder. Which of the following reasons best support the need to insert a foley catheter? Answers.A -D A Accurate I&O B Urinary incontinence C History of UTI’s D Urinary retention A nurse is assessing a client who has diabetic ketoacidosis and positive for ketones in the urine. The nurse should expect which of the following most likely findings? Answers: A – D A Metabolic alkalosis B Blood glucose > 250 C Korsakoff’s respirations D Weight gain A nurse is caring for a client in DKA. The client has been on the DKA insulin drip protocol: insulin has BEEN titrated based on 1 hourly blood glucose checks for several hours and 5% dextrose is infused per protocol. The client’s current blood glucose level is 150 mg/dL and the anion gap is 13. Which of the following would the nurse anticipate to be ordered by the provider next? Answers: A – D A Switch the 5% Dextrose infusion to. 9NS B Discontinue the insulin infusion C Discontinue tho 5% dentoss infusion D Continue the insult infusion A nurse is taking care of a client in septic shock. The client has already received 2 Liters of NS, the 3rd Liter is currently infusing at a rate of 150 ml/hour. The client presents with a urine output of 27 ml for the past hour, a slightly increased HR and RR, and a MAP of 63mm/Hg. Which of the following orders by the provider should the nurse question? Answers: A – D A Administer norepinephrine B Increase normal saline infusion ate to 200mLhr C Administer Furosemide D Administer Hydrocortisone The nurse is caring for a client with acute disseminated intravascular coagulopathy (DIC) who has already started hemorrhaging from every orifice. Which treatment would the nurse anticipate to be ordered for this client? Answers: A -D A Administer oral anticoagulants B Administer fresh frozen plasma C Prepare for plasmapheresis D Calculate the intake and output Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? Answers: A -D A A 42 year old client with a pulmonary embolism B A 35 year old pregnant client with placenta previa C A 78 year old client with sepsis A 60 year old client receiving hemodialysis 3 days week A nurse is caring for a client with 10/10 pain due to compartment syndrome that developed after a burn injury to their left arm. The client is being prepped for a fasciotomy in the OR in 30 minutes. Which nursing intervention could offer the best pain relief for this client while waiting to go to surgery? Answers: A -D A maintain the arm at the level of the heart B Administer 2-4 mg of IV morphine C Administer 1-2 mg of I hydromorphone (dilaudid) D elevate the arm above the level of the heart A nurse is caring for a client with a blood glucose level >250 mg/ dL. in addition to the elevated blood sugar, the nurse knows that if the patient presents with which of the following lab values, the patient would be in DKA? Answers: A -E A Anion gap > 12mEg/L B Ketonuria C Ph <7.30 D All of the above E Positive beta-hydroxybutyrate The nurse is taking care of a diet that suffered a ruptured appendix. and is s/p appendectomy. Currency the client's vitals are stable and labs are WNL except the clients WBC, which is 19. The nurse needs to monitor for which of the following signs or symptoms that could indicate progression to sepsis? Answers. A -D A Hyperthermia and diaphoresis B Hypertension and bradycardia C Polyuria and polydipsia D Hypotension and tachycardia The nurse is caring for a client with a severe infection who developed sepsis. Which of the following are expected findings of a patient with sepsis? Answers: A -D Bradypnea, diaphoresis, bradycardia, hypertension. B Tachypnea, diaphoresis, tachycardia, hypotension C Tachypnea, dry skin, tachycardia. hypertension D Bradypnea, dry skin, bradycardia, hypotension You are caring for a client with a blood pressure of 90/