1 . What assessment findingsshould he nurse document in the electronic medical record for a client who is experiencing autonomic
dysreflexia after a T-4 spinal cord injury
- Severe hypertension, diaphroresis, and flush
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1 . What assessment findingsshould he nurse document in the electronic medical record for a client who is experiencing autonomic
dysreflexia after a T-4 spinal cord injury
- Severe hypertension, diaphroresis, and flushing above the lesion
2 . Asthe nurse isturning a client with a chest tube, the chest tube becomes dislodged from the pleuralspace. What action should
the nurse take first?
- Have the client exhale forcefully and tape 3 sides of a sterile gauze over the insertion site
3 . The nurse plansto administer a low dose prescription for dopamine (Intropin) to a client who is in septic shock. Which physiological
parameter should the nurse use to evaluate a therapeutic response to dopamine?
- Urinary Output
4 . The nurse assesses a male client postoperatively who has an arterial line in the radial artery. Assessment findings include
pallor, parastesia, and slow capillary refill in the client’s right hand fingers. What action should the nurse plan?
- Notify the HCP
5 . A male client is admitted to the cardiac intensive unit with chest pain that began twelve hours ago. The nurse
recognizes increased ventricular ectopy? Based on this assessment finding, what actions is most important for the nurse
to implement?
-Initiate the unit’s antiarrhythmic protocol if symptomatic.
6 . The nurse is assessing a client who was admitted 24 hours ago to the critical care unit following a motorcycle
collision. Which client finding requires intervention by the nurse to reduce the risk for complication related to increased
intracranial pressure?
- Change of PaCo2 to 55 mm Hg following ventilator setting adjustments
7 . A client isreceiving cardiopulmonary resuscitation. After asystole is confirmed in two leads and sending for the transcutaneous
pacemaker, which intravenous medication should be administered?
- Epinephrine
8 . The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to
the hospital with a subarachnoid brain attack (stroke). The client’s Glasgow coma scale is 9. What information is mos
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