Q: A client with burns is admitted, and fluid resuscitation has begun. Central venous pressure (CVP) readings are ordered every 4 hours, and the client's CVP reading is 14 cm H2O. Which evaluation by the nurse would be most accurate?

Answer reason: Normal CVP is about 4–12 cm H2O. A value of 14 cm H2O indicates an elevated preload and fluid overload, consistent with volume excess during resuscitation.

Q: The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?

Answer reason: For organ donor maintenance, the highest priority is preserving organ perfusion via hemodynamic stability; keeping SBP ≥90 mmHg ensures adequate perfusion. Temperature control is supportive, Hct

Q: Which of the following is more life threatening?

Answer reason: BP 80/50 reflects severe hypotension and inadequate perfusion, indicating potential shock and immediate risk to life; the hypertensive readings are less acutely life-threatening in comparison.

Q: The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?

Answer reason: Post–motor vehicle accident with hypotension (80/34) and tachycardia (120) indicates hypovolemic shock from blood loss; the priority nursing diagnosis is fluid volume deficit. Airway appears adequate (RR 20) and no data support cerebral perfusion or sensory deficits.

Q: The nurse is evaluating the client's pulmonary artery pressure. The nurse is aware that this test evaluates?

Answer reason: Pulmonary artery pressure monitoring provides pulmonary artery systolic, diastolic, and mean pressures. It does not directly measure left ventricular pressure (requires wedge), pulmonary vein, or right ventricular pressure.

Question 1

Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure using a pulmonary artery catheter. This action by the nurse will assess?

Accepted Answer

Answer reason: Pulmonary capillary wedge pressure reflects left ventricular end-diastolic pressure, indicating left-sided preload. It does not measure right ventricular pressure, acid-base status, or coronary artery stability.

Question 2

Which healthcare provider's prescription should the nurse implement first for a patient returning from abdominal surgery with a temperature of 100°F, BP 88/60 mm Hg, HR 110, RR 24, oxygen saturation 97%, and CVP 2 mm Hg?

Accepted Answer

Answer reason: Postoperative hypotension with tachycardia and a low CVP (2 mm Hg) indicates hypovolemia. The priority is to restore preload and perfusion with an isotonic fluid bolus. Vasopressors are added only after volume resuscitation; antipyretics and antibiotics are not immediately life-saving.

Question 3

What is the patient's mean arterial pressure (MAP), and how do you interpret the finding for a blood pressure of 80/56?

Accepted Answer

Answer reason: MAP = (SBP + 2×DBP)/3 = (80 + 2×56)/3 = 64 mmHg. Adequate perfusion typically requires MAP ≥ 65–70 mmHg; 64 mmHg is low.

Question 4

A client has a CVP monitor in place. What would be included in the nursing care plan for this client?

Accepted Answer

Answer reason: Normal CVP is about 3–8 cm H2O; values outside this range should be reported. Central line dressings require sterile technique; the head of the bed should not be at 90° for readings, and the zero reference is at the phlebostatic axis (right atrium), not the right clavicle.

Question 5

The nurse is performing fluid resuscitation on a client with burns. Which piece of assessment data is the best indicator that it is effective?

Accepted Answer

Answer reason: For burn resuscitation, adequate tissue perfusion is best assessed by urine output. The target in adults is at least 0.5 mL/kg/hr, commonly ≥ 30 mL/hr. Other signs are less reliable: capillary refill of < 4 seconds is not specific, and tachycardia suggests hypovolemia.

Question 6

A client with burns is admitted, and fluid resuscitation has begun. Central venous pressure (CVP) readings are ordered every 4 hours, and the client's CVP reading is 14 cm H2O. Which evaluation by the nurse would be most accurate?

Accepted Answer

Answer reason: Normal CVP is about 4–12 cm H2O. A value of 14 cm H2O indicates an elevated preload and fluid overload, consistent with volume excess during resuscitation.

Question 7

The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?

Accepted Answer

Answer reason: For organ donor maintenance, the highest priority is preserving organ perfusion via hemodynamic stability; keeping SBP ≥90 mmHg ensures adequate perfusion. Temperature control is supportive, Hct

Question 8

Which of the following is more life threatening?

Accepted Answer

Answer reason: BP 80/50 reflects severe hypotension and inadequate perfusion, indicating potential shock and immediate risk to life; the hypertensive readings are less acutely life-threatening in comparison.

Question 9

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?

Accepted Answer

Answer reason: Post–motor vehicle accident with hypotension (80/34) and tachycardia (120) indicates hypovolemic shock from blood loss; the priority nursing diagnosis is fluid volume deficit. Airway appears adequate (RR 20) and no data support cerebral perfusion or sensory deficits.

Question 10

The nurse is evaluating the client's pulmonary artery pressure. The nurse is aware that this test evaluates?

Accepted Answer

Answer reason: Pulmonary artery pressure monitoring provides pulmonary artery systolic, diastolic, and mean pressures. It does not directly measure left ventricular pressure (requires wedge), pulmonary vein, or right ventricular pressure.

Question 11

A client is being monitored using a central venous pressure monitor. If the pressure is 2 cm of water, the nurse should?

Accepted Answer

Answer reason: Normal CVP is about 5–10 cm H2O. A reading of 2 cm H2O indicates hypovolemia; actions for fluid overload (slow IV, assess for rales, give diuretic) are inappropriate. The nurse should notify the provider for orders to increase fluids.

Question 12

The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60-70 ml per hour to 30 ml per hour. This change is MOST likely due to?

Accepted Answer

Answer reason: Post-MI patients can have reduced cardiac output, lowering renal perfusion and causing a drop in urine output. No evidence of hypovolemia or intrinsic renal failure is provided.

Question 13

Early sign of shock is?

Accepted Answer

Answer reason: In the compensatory (early) stage of shock, baroreceptor-driven sympathetic activation increases heart rate to maintain cardiac output, making tachycardia an early hallmark. Blood pressure is often preserved initially, so hypotension is typically a late finding. Cyanosis develops with more advanced hypoxemia and peripheral vasoconstriction. Oliguria occurs as renal perfusion declines but generally follows the initial tachycardic response.

Question 14

When caring for a client in hemorrhagic shock, how should the nurse position the client?

Accepted Answer

Answer reason: In hemorrhagic shock, positioning supine with the legs elevated (modified shock position) helps promote venous return and temporarily improves preload and cardiac output while definitive treatment (bleeding control and volume resuscitation) is initiated. Trendelenburg is no longer recommended because it can impair ventilation and does not reliably improve perfusion. A semi-sitting position can worsen hypotension by reducing venous return. Simply lying flat without leg elevation provides less circulatory support than the modified shock position.

Question 15

An adult patient arrived in the emergency department (ED) with minor facial lacerations after a motor vehicle accident and has an initial blood pressure (BP) of 182/94. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: An initial markedly elevated BP in the ED after a motor vehicle accident can be transient due to pain, anxiety, or the acute stress response. In the absence of symptoms or signs of hypertensive emergency (eg, neurologic deficits, chest pain, pulmonary edema, acute kidney injury), immediate IV antihypertensives are not indicated and could cause harmful rapid BP reduction. The most appropriate nursing action is to address stabilization and treatment needs first (including pain control and wound care) and then repeat the BP to confirm whether it remains elevated. Admission or extensive counseling is premature until the BP is verified and the clinical context is assessed.

Question 16

A patient has lost a lot of blood from surgery. Which vital sign change would the nurse not expect to see as a result of the massive blood loss?

Accepted Answer

Answer reason: Massive blood loss leads to hypovolemia and shock, which typically causes compensatory tachycardia and hypotension along with increased respiratory rate to improve oxygen delivery. A respiratory rate of 8/min indicates bradypnea and hypoventilation, which is not an expected compensatory response to hemorrhage (unless due to CNS depression, opioids/anesthesia, or impending respiratory failure). Therefore, RR of 8 is the vital sign change the nurse would not expect from blood loss alone. HR 118 and BP 80/45 are consistent with hypovolemic shock.

Question 17

What is the best position for a client in shock?

Accepted Answer

Answer reason: In shock, the immediate goal is to support circulation and improve venous return to increase preload and cardiac output. Placing the client supine with legs elevated (modified Trendelenburg) can transiently enhance perfusion to vital organs when there is no contraindication (e.g., suspected spinal injury, respiratory distress, increased intracranial pressure). Fowler's position can reduce venous return and worsen hypotension. Side-lying or prone do not generally optimize hemodynamics for undifferentiated shock.

Question 18

A client delivered twins 1 hour ago and reports dizziness and palpitations. HR is 118, BP 84/50, fundus is boggy. What is the priority action?

Accepted Answer

Answer reason: Findings (boggy fundus, hypotension, tachycardia, dizziness) indicate postpartum hemorrhage most likely due to uterine atony, which is common after overdistention (twins). The immediate priority is to promote uterine contraction to reduce bleeding, and the fastest first-line nursing action is fundal massage. Oxytocin and IV fluids are also important, but fundal massage is the most immediate intervention to correct uterine atony and stabilize hemodynamics. Assessing for retained placental fragments is not the first priority when a boggy uterus suggests atony.

Question 19

A postpartum nurse is assessing a client 12 hours after a vaginal delivery. Which finding requires immediate intervention?

Accepted Answer

Answer reason: A perineal pad saturated within 30 minutes indicates heavy postpartum bleeding and is concerning for postpartum hemorrhage, which can rapidly lead to hypovolemia and shock. This requires immediate assessment of uterine tone, quantification of blood loss, vital signs, and prompt interventions (e.g., fundal massage and escalation for uterotonics per protocol). The other findings are expected at ~12 hours postpartum: a firm midline fundus at the umbilicus, lochia rubra with small clots, and mild afterpains responsive to NSAIDs.

Question 20

A nurse notices a sudden drop in blood pressure and pulse in a patient receiving spinal anesthesia. What should the nurse do first?

Accepted Answer

Answer reason: Spinal anesthesia can cause sympathetic blockade leading to vasodilation, decreased venous return, and rapid hypotension with bradycardia, so immediate hemodynamic support is the priority. Administering IV fluids and ordered vasopressors directly treats the underlying low preload and vascular tone to restore perfusion. Trendelenburg positioning may be adjunctive but is not as definitive as pharmacologic and volume resuscitation. Notifying the surgeon can occur after initiating stabilization, and pain medication is not indicated for this hemodynamic emergency.

Question 21

In shock, the patient is kept in?

Accepted Answer

Answer reason: In shock, the priority is to improve perfusion to vital organs by supporting venous return and cardiac output. Keeping the patient supine with legs elevated (often described as Trendelenburg or modified Trendelenburg) can transiently increase venous return and support blood pressure while definitive treatment is initiated. High Fowler’s can reduce venous return and worsen hypotension, while prone and lithotomy are not standard positions for shock resuscitation. Therefore, the best choice is supine with legs elevated.

Question 22

In shock management, the first target is to restore?

Accepted Answer

Answer reason: The primary goal in shock management is restoration of adequate tissue perfusion to ensure sufficient oxygen and nutrient delivery to vital organs. Blood pressure, heart rate, and oxygen saturation are important indicators, but they are secondary targets and do not always reflect effective microcirculatory perfusion.

Question 23

The best strategy to prevent maternal deterioration in APH is?

Accepted Answer

Answer reason: Antepartum hemorrhage (APH) can rapidly cause hypovolemia and hemorrhagic shock, so preventing maternal deterioration focuses on maintaining circulating volume and oxygen-carrying capacity. Having blood available and initiating transfusion when indicated is a direct, life-preserving intervention to stabilize hemodynamics. Monitoring fundal height does not address acute blood loss, and ambulation can worsen bleeding/instability. A high-calorie diet is not an immediate strategy for preventing acute maternal decline in APH.

Question 24

The nurse assesses a client who has new onset atrial fibrillation. The ventricular rate is 145 beats/min. What does the nurse expect to observe?

Accepted Answer

Answer reason: New-onset atrial fibrillation with a rapid ventricular response (145/min) reduces diastolic filling time and eliminates the atrial kick, which can decrease cardiac output. Decreased cardiac output commonly produces symptoms of cerebral and systemic hypoperfusion such as dizziness, and pulmonary congestion/poor oxygen delivery causing dyspnea. Peripheral edema and JVD are more consistent with chronic right-sided heart failure or significant volume overload rather than an acute tachyarrhythmia presentation. Head and neck pain is not a typical expected finding of atrial fibrillation with RVR.

Question 25

Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?

Accepted Answer

Answer reason: In hypovolemic shock, adequate fluid resuscitation is best reflected by improved end-organ perfusion, and urine output is a direct, sensitive indicator of renal perfusion. A urine output of at least 30 mL/hr in adults is commonly used as a target for adequate circulating volume and cardiac output. Blood pressure can lag behind or be supported by vasoconstriction/vasopressors and is less reliable as the best single indicator. A respiratory rate of 21/min is nonspecific and does not directly confirm adequate perfusion.

Question 26

Which IV fluid is best for trauma patients?

Accepted Answer

Answer reason: In trauma with suspected hemorrhagic shock, initial resuscitation typically uses isotonic crystalloids; Ringer’s lactate is commonly preferred because it is a balanced solution that approximates extracellular fluid and helps restore intravascular volume. Dextrose-containing fluids are not appropriate for volume resuscitation and can worsen hyperglycemia. Hypertonic saline (3% NaCl) is reserved for specific indications (e.g., severe symptomatic hyponatremia or certain neuro/ICP protocols), not routine trauma resuscitation. Normal saline is acceptable, but large volumes can contribute to hyperchloremic metabolic acidosis, making RL often the better choice when available.

Question 27

A client with a spinal cord injury at T4 develops neurogenic shock. Which finding should the nurse expect?

Accepted Answer

Answer reason: Neurogenic shock after a high spinal cord injury causes loss of sympathetic tone, leading to peripheral vasodilation and hypotension. Unlike most other shock states, unopposed vagal tone produces bradycardia rather than tachycardia. Vasodilation also results in warm, dry skin due to increased cutaneous blood flow and impaired thermoregulation. Therefore the expected triad is hypotension, bradycardia, and warm dry skin.

Question 28

A 2-year-old is brought to the ER with severe dehydration due to gastroenteritis. Which finding requires immediate intervention?

Accepted Answer

Answer reason: A heart rate of 180 bpm in a 2-year-old with severe dehydration is a sign of significant hypovolemia and possible progression toward shock, requiring immediate stabilization (airway/breathing/circulation) and rapid fluid resuscitation. While delayed capillary refill and sunken fontanel indicate dehydration, extreme tachycardia suggests worsening circulatory compromise. Urine output of 1 mL/kg/hr is within expected minimum pediatric output and is not an urgent abnormality. Therefore, the most immediately concerning finding is the marked tachycardia.

Question 29

What's the primary feature of hypovolemic shock?

Accepted Answer

Answer reason: Hypovolemic shock is characterized by decreased circulating volume, leading to reduced cardiac output. The body compensates initially by activating the sympathetic nervous system, resulting in tachycardia to maintain perfusion. Hypertension, warm skin, and decreased respiratory rate are inconsistent with hypovolemic shock physiology.

Question 30

Which of the following is a common early sign of hypovolemic shock?

Accepted Answer

Answer reason: In the early (compensated) stage of hypovolemic shock, peripheral vasoconstriction occurs to preserve blood flow to vital organs. This results in cool, pale, clammy skin. Hypotension and oliguria are later findings, while bradycardia and increased urine output are inconsistent with shock.

Question 31

The nurse is assisting with caring for a client with abruptio placenta. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first?

Accepted Answer

Answer reason: C. Turn the client onto her side. In suspected shock with abruptio placenta, immediate positioning to optimize maternal circulation and uteroplacental perfusion is a priority; left lateral positioning reduces aortocaval compression by the gravid uterus and can improve venous return and cardiac output. The other options are important assessments, but they do not immediately correct a reversible cause of worsening hemodynamics. After positioning, rapid vital sign monitoring, fetal assessment, and preparation for emergent management (e.g., IV access/fluids/blood) follow per protocol.

Question 32

A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia, and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment?

Accepted Answer

Answer reason: A blood transfusion. A postpartum blood loss of 700 mL with vital signs showing hypovolemia indicates hemorrhagic shock risk, so restoring circulating volume and oxygen-carrying capacity is urgent. Because the uterus remains atonic despite treatment, initial uterotonic measures (e.g., oxytocin, fundal massage) have been inadequate and the priority becomes stabilization of hemodynamics. Blood transfusion is indicated when there are signs of significant hypovolemia and ongoing/clinically important blood loss to prevent end-organ hypoperfusion.

Question 33

A pregnant woman at 32 weeks gestation is admitted with painless vaginal bleeding. What is the nurse’s priority intervention?

Accepted Answer

Answer reason: Insert an IV line with large-bore cannula Painless third-trimester bleeding is concerning for placenta previa, which can cause significant maternal hemorrhage. The immediate priority is maternal stabilization and preparation for potential rapid blood/fluid resuscitation, best achieved by establishing large-bore IV access. Vaginal examination is contraindicated until previa is ruled out because it can provoke severe bleeding. Continuous fetal monitoring is important but follows initial maternal stabilization; oxytocin is not the first-line intervention in suspected placenta previa with bleeding.

Question 34

A nurse is caring for a patient experiencing shock. Which of the following signs would the nurse expect to assess?

Accepted Answer

Answer reason: Hypotension Shock is defined by inadequate tissue perfusion, and a common late/significant finding across many types of shock is decreased systemic blood pressure due to reduced effective circulating volume and/or reduced cardiac output. Compensatory responses (e.g., tachycardia, vasoconstriction) may initially maintain blood pressure, but as compensation fails, hypotension becomes evident. The other options (bounding pulses, bradycardia, hypertension) are not typical expected findings in most shock states.

Question 35

After cardiac surgery, a client’s blood pressure measures 126/80. The nurse determines that the mean arterial pressure (MAP) is which of the following?

Accepted Answer

Answer reason: MAP is estimated as diastolic pressure plus one-third of the pulse pressure: MAP ≈ DBP + (SBP − DBP)/3. With 126/80, pulse pressure is 46, one-third is about 15.3, and adding to 80 gives about 95.3 mm Hg. Since 95 mm Hg is not offered as an exact choice in the options list for the computed value to one decimal and typical rounding is to the nearest whole number, the closest provided option is selected for clinical approximation.

Question 36

The nurse observes that a client with heart failure has not voided for 6 hours despite receiving IV fluids. What is the priority action?

Accepted Answer

Answer reason: In a client with heart failure, decreased urine output after IV fluids can indicate worsening fluid overload and reduced renal perfusion related to impaired cardiac output. Assessing lung sounds is the fastest bedside assessment to identify pulmonary congestion/edema, which is an immediate, potentially life-threatening complication affecting oxygenation. This assessment guides urgent next steps (e.g., slowing fluids, diuretics, oxygen) before proceeding to invasive measures or lab evaluation. Catheterization, labs, and provider notification may be needed, but rapid respiratory status assessment is the priority.

Question 37

A patient in active labor is in a supine position with continuous fetal monitoring. The nurse observes a pattern of late decelerations. Which action should the nurse take first?

Accepted Answer

Answer reason: Late decelerations are most consistent with uteroplacental insufficiency and fetal hypoxia, and the fastest independent nursing action is maternal repositioning to improve uterine perfusion and relieve aortocaval compression from the supine position. Turning to the left side can quickly increase venous return and placental blood flow, often improving the fetal heart rate pattern. Other measures (stopping oxytocin, IV fluid bolus, and notifying the provider) may also be needed, but repositioning is the immediate first step that can be done without delay.

Question 38

The nurse is reviewing vital signs for four post-op clients. Which one should be seen first?

Accepted Answer

Answer reason: Tachycardia combined with hypotension in a post-operative patient suggests possible hypovolemia or hemorrhage and represents an immediate threat to circulation.

Question 39

A client in labor has variable decelerations on the fetal heart monitor. What is the priority nursing intervention?

Accepted Answer

Answer reason: Variable decelerations are most commonly caused by umbilical cord compression, so the immediate priority is to relieve compression and improve uteroplacental perfusion. Repositioning the mother (e.g., lateral position, knee-chest) is a rapid, first-line intrauterine resuscitation measure that can reduce cord compression and improve fetal oxygenation. IV fluids may be an adjunct if maternal hypotension is contributing, but it is not the fastest, most direct intervention for variable decelerations. Immediate delivery is reserved for persistent nonreassuring patterns unresponsive to corrective measures, and pushing can worsen fetal stress if the tracing is concerning.

Question 40

A nurse observes late decelerations on the fetal heart rate (FHR) monitor. What is the priority nursing action?

Accepted Answer

Answer reason: Late decelerations indicate uteroplacental insufficiency with decreased fetal oxygenation, so the first intervention is to improve uterine blood flow. Left lateral positioning reduces aortocaval compression, increases venous return and cardiac output, and can quickly improve placental perfusion and fetal oxygen delivery. If the pattern persists, additional intrauterine resuscitation (e.g., oxygen, IV fluid bolus, stopping oxytocin if infusing) and prompt provider notification/escalation are indicated, with operative delivery considered if unresolved.

Question 41

The nurse is caring for a client who is hypotensive and has cold, mottled extremities. What is the best position for this client?

Accepted Answer

Answer reason: Hypotension with cold, mottled extremities suggests poor peripheral perfusion and possible shock physiology. Elevating the legs in the supine position transiently increases venous return (preload) to improve cardiac output and systemic perfusion while further assessment and treatment are initiated. Prone and high Fowler’s can reduce venous return and potentially worsen hypotension, and keeping legs flat does not provide the same immediate circulatory support.

Question 42

After unilateral adrenalectomy, what should the nurse assess most urgently?

Accepted Answer

Answer reason: A. Blood pressure After adrenal surgery, acute changes in adrenal hormone levels can cause rapid hemodynamic instability, including hypotension and shock. Blood pressure is the earliest and most critical indicator of inadequate perfusion requiring immediate intervention (e.g., fluids, vasopressors, steroid support if indicated). Temperature and urine measures are important postoperative assessments but are less immediately life-threatening than an abrupt blood pressure change in this context.

Question 43

In neonatal septicemia, which of the following measure is used to improve perfusion-?

Accepted Answer

Answer reason: Neonatal sepsis can cause vasodilation, capillary leak, and relative hypovolemia, leading to poor tissue perfusion and hypotension. An isotonic crystalloid bolus is the first-line immediate intervention to restore intravascular volume and improve cardiac output/perfusion. Dextrose bolus treats hypoglycemia, vitamin K prevents bleeding, and antibiotics treat the infection source but do not rapidly correct shock-related perfusion deficits in the moment.

Question 44

A nurse is caring for a client who is post-op following abdominal surgery. Which of the following findings is the most concerning and requires immediate action?

Accepted Answer

Answer reason: This indicates hypotension that can reflect acute blood loss, third-spacing, or evolving shock in the immediate postoperative period. Hemodynamic instability threatens perfusion to vital organs and requires rapid assessment (bleeding, drain output, incision, mental status, urine output) and prompt intervention (notify provider/rapid response, IV fluids/blood as ordered). The other findings can be expected post-op or are less immediately life-threatening compared with compromised circulation.

Question 45

When performing a postpartum fundal assessment the nurse assess the patient’s uterus and notes that it feels soft and spongy. What are the best initial nursing actions?

Accepted Answer

Answer reason: A soft, “boggy” postpartum uterus indicates uterine atony, the most common cause of postpartum hemorrhage. The priority initial nursing intervention is to stimulate uterine contraction by performing gentle fundal massage to restore tone and reduce bleeding risk. While assessing lochia for increased bleeding/clots and documenting findings are important, they come after the immediate corrective action. The provider is notified if massage does not firm the uterus or bleeding persists despite initial measures.

Question 46

The nurse is assessing a client immediately following delivery. The nurse notes that the client’s fundus is boggy. The nurse’s next action should be to?

Accepted Answer

Answer reason: A boggy fundus indicates uterine atony, a leading cause of postpartum hemorrhage, so the priority is to promote uterine contraction immediately to reduce bleeding risk. Fundal massage helps the uterus firm up and clamp down on uterine vessels. After massaging, the nurse should reassess firmness and lochia and then evaluate contributing factors such as a distended bladder and the need for uterotonic medications per protocol.

Question 47

The nurse caring for a patient following a bowel resection noticed that the patient is restless. The nurse checks the patient’s vital signs and notes that the pulse rate has increased and the blood pressure has dropped significantly since the previous reading. The nurse suspects that the patient is going into shock and which immediate action should be taken?

Accepted Answer

Answer reason: The findings suggest acute circulatory compromise with tachycardia and hypotension, consistent with developing shock after surgery. Elevating the legs (modified Trendelenburg/leg raise) transiently increases venous return (preload) to support cardiac output and perfusion while additional emergency measures are initiated. The other choices are either confirmatory rather than immediately supportive (rechecking VS, checking SpO2) or potentially harmful in shock by reducing circulating volume support (slowing IV fluids).

Question 48

A nurse is caring for a patient with sepsis who has a mean arterial pressure (MAP) of 58 mmH. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason:  A MAP of 58 mmHg in sepsis indicates inadequate tissue perfusion (goal is typically ≥65 mmHg), making hemodynamic support the immediate priority. Rapid IV fluid resuscitation is first-line to improve preload, cardiac output, and perfusion before non-urgent measures. Simply waiting to recheck delays treatment of shock, and elevating the head to 90 degrees can worsen venous return and hypotension. Treating fever may improve comfort but does not address the immediate perfusion-threatening problem.

Question 49

The trauma nurse expects vasopressors to be used in the treatment of:

Accepted Answer

Answer reason:  This condition causes obstructive shock due to impaired ventricular filling, leading to hypotension and poor tissue perfusion. Vasopressors may be used as a temporary measure to support blood pressure and maintain perfusion while definitive treatment (urgent pericardiocentesis or surgical drainage) is arranged. In contrast, the other options are primarily managed with supportive respiratory care (fat embolism, pulmonary contusion) or urgent fasciotomy for limb-threatening ischemia (compartment syndrome), rather than vasopressors as a key therapy.

Question 50

A nurse is caring for a postoperative patient who suddenly reports feeling dizzy and lightheaded. The nurse checks the patient's vital signs and notes: BP: 88/54 mm Hg, HR: 112 bp, RR: 22 breaths/min, Temp: 36.8°C (98.2°F), Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: The patient is hypotensive with compensatory tachycardia and symptoms of decreased cerebral perfusion, suggesting acute hemodynamic instability. Immediate positioning improves venous return and cardiac output to support blood pressure and perfusion while further assessment and interventions are initiated. Waiting to recheck delays treatment, and notifying the provider is important but not the first action when a rapid, nurse-initiated stabilization measure is available. IV fluids may be needed but should follow immediate supportive measures and verification of orders/access while simultaneously assessing for causes such as bleeding.
Category reason: This is a priority nursing action question requiring immediate intervention to stabilize perfusion and blood pressure in a symptomatic postoperative patient, which fits hemodynamic management under Physiological Adaptation.

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