Download NURS 487 Week 11 Final Exam Latest 2025 EXAM WITH ANSWERS (100 QUESTIONS) GRADED A+ and more Exams Nursing in PDF only on Docsity!
What is an indicator/ symptom that shock is progressing? In the early stage of septic shock, the patient has warm and dry skin. Cool and clammy skin would indicate that the shock is progressing. neurogenic shock Circulatory failure caused by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries. What are the hallmark symptoms of Neurogenic shock? hypotension and bradycardia. What are four of the manifestations of septic shock?
- Increased cardiac output
- warm, flushed skin
- fever and chills
- vasodilation What is a symptom in anaphylactic shock? Angioneurotic edema.
NURS 487 Week 11 Final Exam Latest 2025
EXAM WITH ANSWERS (100 QUESTIONS)
GRADED A+
What is one of the hallmark symptoms of ARDS? hypoxemia. What is MODS (multiple organ dysfunction syndrome) progressive dysfunction of two or more organ systems due to pro-inflammatory state such as SIRS or Septic shock What is an indication that a patient may be going from cardiogenic shock into MODS? The elevated serum creatinine level indicates that the client has renal failure as well as heart failure. What are some symptoms of cardiogenic shock? Crackles, chest pressure, and cool extremities are all consistent with cardiogenic shock. What symptoms are suggestive of ARDS? Septicemia and laboured breathing suggest the onset of ARDS What is the purpose of prone positioning? to improve the client's oxygenation as indicated by the PaO2 and SaO2. What is intracellular fluid?
What is the purpose of sodium? 90% of the ECF, works with K+ and Ca++ to conduct nerve impulses and regulate acid-base balance and membrane transport Sodium (cation or anion, ECF or ICF, controlled by what? Roles?)
- primary ECF cation
- controlled by the kidneys/ aldosterone
- roles: neuromuscular irritability, acid-base balance, membrane transport What is the purpose of chloride? (cation or anion, ECF or ICF, roles)
- Primary ECF anion
- provides electroneutrality What is the renin-angiotensin-aldosterone system? (steps, overall effect)
- Body's response to low BP/ BV
- ADH is released from the posterior pituitary
- ADH + Renin = angiotensin I
- ACE + angiotensin I = angiotensin II
- Aldosterone & ADH are increased ***OVERALL: increased extracellular fluid/ increased blood volume, increase blood pressure, vasoconstriction, increased sodium and water retention
What happens when a hypotonic solution is administered? When a hypotonic solution is administered, it puts more water in the serum than is found inside cells. As a result, water moves into the cells, causing them to swell. What is a hypotonic solution? (purpose, when is it used, who should you not give it to?)
- Fluid goes into the cell
- for patients with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemia.
- DO NOT GIVE TO PATIENTS WITH BRAIN INJURIES (cerebral edema, increased ICP, burns) because you can deplete their fluid volume. What happens when a hypertonic solution is administered? hypertonic fluids cause an increased concentration of dissolved solutes in the intravascular space compared to the cells. This causes the movement of water out of the cells and into the intravascular space to dilute the solutes in the blood. What is a hypertonic solution? (purpose, when is it used)
- pulls the h2o & sodium out
- Used in patients with cerebral edema (drawing fluids out of the cell to increase the solute in the plasma)
- TREATMENT OF HYPONATREMIA, DECREASED ICP, REPLACEMENT OF ELECTROLYTES, TREAT SHOCK What is an isotonic solution? (purpose, when is it used, who should you not give it to?)
- Contains equal concentrations of solutes on both sides.
- used to replace extracellular fluid losses (dehydration)
Back & Gluteal: 18% Groin: 1% Fronts of Arms: 4.5% Backs of Arms: 4.5% Fronts of Legs: 9% Backs of Legs: 9% Hypovolemia in the early stages of burns is related to... increased capillary permeability and evaporative water loss Interpret this ABG result: pH- 7.32, CO2- 37, HCO3- 16 uncompensated metabolic acidosis A chronic lung disease patient has a sudden onset of agitation and confusion, which action would be a priority? assess oxygenation using the pulse ox Sepsis leaves a patient most prone to MODS. True or False? True When a patient is in shock, the nurse knows its impairment in cellular metabolism is caused by... inadequate tissue perfusion
A cardiac monitor shows premature ventricular contraction (PVCs). Which lab value would the nurse relate this to? Serum potassium of 2. What are the different types of distributive shock? Septic shock, anaphylactic shock, neurogenic shock "Third-spacing" refers to when the fluid moves into the extravascular space. True or False? True Neurogenic shock can be caused by any factor that inhibits the... Sympathetic Nervous System What are the types of burn depths? (what degree and what they affect)
- First degree: epidermis only, local pain/ erythema
- Second degree: superficial partial thickness (epidermis and some dermis), deep partial thickness (epidermis and dermis)
- Third degree: full thickness (epidermis, dermis, and subcutaneous tissue) What is the compensatory stage of shock? (what is the BP, HR, respiratory status, skin, urinary output, mental status, and acid-base balance)
Skin: jaundiced Urine output: anuric, requires dialysis Mental status: unconscious Acid-base balance: profound acidosis What is the diagnostic criteria for SIRS? MUST HAVE AT LEAST 2
- Temp: >38 or <
- HR: >
- WBC: >10% bands
- RR: >20 or PaCO2 < What is potassium? (purpose, ECF or ICF, cation or anion, what regulates K+)
- in the transmission and conduction of nerve impulses, muscle contractions, cardiac rhythm
- ICF cation
- Aldosterone and insulin regulated K+ (the kidneys) What is hypokalemia? (causes, symptoms, ECG changes, what decreases it?)
- A serum potassium level less than 3.5 mEq/L.
- Causes: decreased intake, alkalosis
- INSULIN= decrease in potassium
- ECG: decreased T wave, st depression, prolonged QT, increased P wave
- Symptoms: constipation, paralytic iliases
What is hyperkalemia? (causes, symptoms, ECG changes)
- A serum potassium level that exceeds 5.5 mEq/L.
- Causes: decreased insulin, DKA
- Symptoms: muscle weakness, paralysis
- INCREASED T-WAVE AND HYPERACTIVE PERISTALSIS What is calcium? (purpose) for muscle contractility, heart conduction, blood clotting What is hypocalcemia? (symptoms)
- A serum calcium level less than 2.1 mg/dL.
- nervousness, excitability, tetany What is hypercalcemia? (symptoms)
- A serum calcium level that exceeds 2.6 mg/dL.
- N/V, coma, fatigue What is the purpose of magnesium? for metabolic processes What is hypomagnesemia? (symptoms)
What are the purpose of RBC/ erythrocytes? tissue oxygenation What are the purpose of plasma? blood volume, injury recovery What are the purpose of leukocytes? defense against infection What are the types of leukocytes? Granulocytes: neutrophils, eosinophils, basophils Agranulocytes: lymphocytes, monocytes What is the clotting mechanism/ cascade steps?
- injury occurs
- platelet plug formation
- fibrin clot development
- clot retraction/ dissolution What is anemia? (lab value, causes, assessments, diagnostics)
- Anemia is a deficiency in red blood cells or hemoglobin.
- normal= 120 - 180
- causes: blood loss, decreased RBC production, RBC destruction
- assessments: look at the meds (ASA, anticoagulants)
- diagnostics: decreased RBC, increased reticulocyte What are the manifestations associated with anemia depending on lab value? 100 - 120= no symptoms, minor palpations 60 - 100= bounding pulse, dyspnea, fatigue <60= pallor, jaundice, blurred vision, tachycardia, angina, decreased O What can cause low magnesium? ALCOHOLISM What are the organs associated with the immune system? the spleen (filters antigens), the thalamus (cell-mediated response), and lymph nodes (filters the blood) What is thrombocytopenia? (diagnostics)
- low platelet count <
- diagnostics: ++ d-dimer, normal INR/ PTT, decreased platelets What is HIT? (due to what type of heparin, causes, diagnostics)
- heparin-induced thrombocytopenia
What are the manifestations associated with the volume of blood loss for acute blood loss? 500mL= no symptoms, minor syncope 1000mL= tachycardia & hypotension with exercise 1500mL= normal BP and P, postural hypotension 2000mL= decreased BP and CO, air hunger, rapid pulse, cool/ clammy skin 2500mL= shock, lactic acidosis, death What are the two types of immunity? innate (non-specific) and acquired (specific) What are the two types of acquired immunity? active (immunizations, past pathogens) and passive (breastfeeding) What is the antigen-antibody response? occurs when white blood cells/ antibodies recognize a substance as foreign/ antigen and try to destroy it What is the humoral response? (what cells, produces what, protects against?)
- b lymphocytes
- produces antibodies
- protects against bacteria
What is the cell- mediated response? (what cells, produces what, protects against?)
- t lymphocytes/ macrophages
- produces t cells & cytokines
- protects against fungi What are the four types of hypersensitivity reactions?
- anaphylactic
- cytotoxic
- immune complex
- allergies/ delayed/ type 1 What Ig is responsible for anaphylaxis? IgE What is an atopic reaction? minor allergic reaction (rash, hives, runny nose) What are manifestations and diagnostics for hypersensitivity reactions?
- manifestations: bronchoconstriction, airway edema, hypotension, N/V
- diagnostics: CBC, increased eosinophil What is anaphylaxis? (manifestations, what should you monitor for)
What is included in the inflammatory response? vascular response, cell response What are the 3 types of inflammation? acute- 2 to 3 weeks subacute- weeks to months chronic- months up to years What are the 3 healing intentions? Primary intention: within the first 4 days, vasodilation occurs Secondary intention: trauma wounds, +++ exudate, the incision is wide and will close by itself Tertiary intention: delayed primary intention, an open wound What are the ways a wound is classified? Causes (surgical/ non-surgical, acute/ chronic), level of contamination, depth of the affected tissue, color What are the types of isolation? (types of PPE) contact, droplet, airborne (gloves, gown, visor, googles, mask) What is neutropenia? (causes, manifestations, diagnostics)
- causes: use of chemotherapy, immunosuppressants
- manifestations: sore throat, dysphagia, SOB, cough, pain
- diagnostics: Hct, WBC, reticulocyte What is the problem with the use of antipyretics and febrile neutropenia? they can mask the underlying fever What is sepsis? infection in the blood stream What are the steps in sepsis development? (4)
- The antigen enters the body
- the inflammatory response is triggered
- there is an exaggerated response
- endothelial injury occurs= vasodilation What lab value is decreased in sepsis? decreased coagulation factor = DIC What are some of the manifestations of sepsis? tachypnea, tachycardia, altered LOC, decreased urine output, increased creatinine, hypoactive bowel sounds, hyperglycemia, cool/ clammy skin, hypotension
