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Patient Review Asses
Patient Review Assessment Performance
| Question | Answer |
|---|---|
| Which of the following assessment findings are consistent with volume depletion with dehydration? | - Capillary refill time greater than 3 seconds - Sinus tachycardia - Weak peripheral pulses (+1) - Dry skin with poor turgor - BP 80/45 - Oliguria |
| Anticipating fluid replacement for Mrs. Wilson, which IV solution do you prepare? | Isotonic saline |
| Assessing for signs of fluid overload is important. Which of the following assessment findings could occur as signs of fluid volume overload? | - S3 heart sound (ventricular gallop) on cardiac auscultation - Fine crackles auscultated at lung bases - Decreased oxygen saturation by pulse oximeter (SpO2) |
| Which of the following characterizes fluid shift when serum osmolality is elevated? | Water moves from the intracellular fluid (ICF) to the extracellular fluid (ECF) |
| Fluid replacement and insulin will be important treatments for Mrs. Wilson. Insulin will be administered IV. Which type of insulin should you have available for IV use? | - Regular insulin |
| You observe a focal seizure that starts in Mrs. Wilson's right hand. Which of the following characterizes a focal seizure? | Spasmodic movement confined to a specific body part |
| Which of the following actions on your part is indicated in response to the order for Dilantin (phenytoin sodium)? | Question the order for Dilantin (phenytoin sodium) |
| Nursing interventions designed to prevent injury from seizures include: | - removing potentially injurious objects away Mrs. Wilson's immediate area -keeping suction equipment available - padding of Mrs. Wilson's side rails |
| You know that Mrs. Wilson is being intubated to: | preserve her airway |
| Mrs. Wilson's low values for cardiac output and cardiac index are probably due to inadequate: | - preload |
| Mrs. Wilson's daughter asks about her mother's prognosis. Although the physician is better prepared to discuss this with her, you are aware that: | hyperglycemic hyperosmolar state (HHS) is life-threatening, with a significant mortality rate |
| Nursing care of Mrs. Wilson must address numerous problems. These include: | - Deficient Fluid Volume - Risk for Aspiration |
| Ongoing assessment of Mrs. Wilson is important. Which of the following evaluation criteria would indicate a positive, successful outcome to fluid resuscitation? | - Urine output of 100 mL per hour - Right atrial pressure (RAP) of 6 mm Hg (earlier reading 1 mm Hg) - Cardiac output (CO) of 5 L/minute (earlier reading 3 L/minute) - Serum osmolality of 300 mOsm/kg H2O (earlier value 365 mOsm/kg H2O) |
| Interventions aimed at identifying/preventing deep vein thrombosis (DVT) include: | - graduated compression stockings - passive range of motion exercises to the extremities - frequent assessment of the lower extremities for warmth, tenderness, and swelling - frequent assessment of peripheral pulses |
| At 3 PM, Mrs. Wilson's cardiac monitor alarm sounds. Her ECG waveform indicates: | ventricular fibrilation |
| The definitive treatment required for a successful outcome at this time is: | defibrillation |
| A defibrillator is in the ICU but not readily available at Mrs. Wilson's bedside. What should you do? | Begin cardiopulmonary resuscitation (CPR) but defibrillate Mrs. Wilson as soon as the defibrillator arrives at the bedside |
| Mrs. Wilson's daughter is present when she "codes." As a patient/family advocate you: | encourage the code team to allow her to stay in the room |
Created by:
Brandi Sizemore
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