TEST BANK FOR INTRODUCTION TO CRITICAL CARE NURSING 8TH EDITION SOLE KLEIN MOSELEY -GRADE BOOSTER -2

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School

Walden University *

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Course

6002

Subject

Nursing

Date

Nov 24, 2024

Type

pdf

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Uploaded by SuperHumanFrogMaster1106

? As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO 2 45 mm Hg, HCO 3 18 indicates metabolic acidosis and progression to a late stage of shock. All other listed arterial blood gas values are within normal limits. DIF: Cognitive Level: Application OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 29. The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? a. Administer pain medication. b. Turn patient every 2 hours. c. Assess core body temperature. d. Apply bilateral heel protectors. ANS: C Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body temperature is a priority. While administration of pain management, repositioning the patient every 2 hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario. DIF: Cognitive Level: Application OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 30. The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician’s order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m 2 . The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m 2 . What is the best action by the nurse?

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