NUR 221 EXAM 3 NEWEST 2024 ACTUAL

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NUR 221 EXAM 3 NEWEST 2024 ACTUAL

EXAM COMPLETE 200+ EXAM QUESTIONS

AND CORRECT ANSWERS (VERIFIED

ANSWERS) |ALREADY GRADED A+||BRAND

NEW VERSION!!

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team?

• Frequent turning
• Monitoring intake and output
• Enteral feedings
• Pain management - ANSWER- C. Enteral feedings

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy?

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• Normal body temperature
• Balanced intake and output
• Adequate pain management
• Urine output of 0.5 mL/kg/hr - ANSWER- D. Urine output of

0.5 mL/kg/hr

The nurse is caring for a 70-kg patient in hypovolemic shock.Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following primary care provider rounds, the nurse reviews the orders and questions which order?

• Administer acetaminophen 650-mg suppository prn every 6

hours for pain.

• Titrate dopamine intravenously for blood pressure less than

90 mm Hg systolic.

• Complete neurological assessment every 4 hours for the next

24 hours. 2 / 4

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• Administer furosemide 20 mg IV every 4 hours for a CVP

greater than 20 mm Hg. - ANSWER- B. Titrate dopamine intravenously for blood pressure less than 90 mm Hg systolic.

The nurse is administering intravenous norepinephrine at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter.What assessment finding requires immediate action by the nurse?

• Blood pressure 100/60 mm Hg
• Swelling at the IV site
• Heart rate of 110 beats/min
• Central venous pressure (CVP) of 8 mm Hg - ANSWER- B.

Swelling at the IV site

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m 2 , heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm 5 . Upon review of primary care provider orders, which order is most appropriate for the nurse to initiate?

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• Furosemide 20 mg intravenous (IV) every 4 hours as needed

for CVP > 20 mm Hg

• Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as

needed for chest pain

• Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as

needed for CI < 2 L/min/m 2

• Dopamine infusion at a rate of 5 to 10 mcg/kg/min to

maintain a systolic BP of at least 90 mm Hg - ANSWER- B.Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central line associated bloodstream infection

(CLABSI)?

• Documentation of insertion date
• Elevation of the head of the bed
• Assessment for weaning readiness
• Appropriate sedation management - ANSWER- A.

Documentation of insertion date

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