NU335 Spring 2026 T2 CA CV Disorder Shock Emergency at Baton Rogue General School of Nursing
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Free NU335 Spring 2026 T2 CA CV Disorder Shock Emergency at Baton Rogue General School of Nursing Questions
The nurse's priority in the care of a patient with a suspected acute aortic dissection will include which intervention to prevent rupture?
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Reduce anxiety.
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Increase myocardial contractility.
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Control blood pressure.
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Monitor for chest pain.
Explanation
Explanation
The priority intervention in the management of acute aortic dissection is to control blood pressure, specifically reducing systolic blood pressure to 120 mmHg or lower and managing heart rate to decrease the shearing forces on the aorta. Uncontrolled high blood pressure can increase the risk of rupture or worsening of the dissection, making it the most critical intervention to prevent further damage and improve the patient’s outcomes. Medications such as beta-blockers or vasodilators may be used to control blood pressure and reduce the strain on the aorta。Correct Answer Is:
C. Control blood pressure.A patient receiving radiation to the head and neck area as treatment for laryngeal cancer develops ulcerations and bleeding of the oral mucosa. What should the nurse consider as the primary goal for this patient?
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Relief of anxiety
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Pain relief
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Increase in self-esteem
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Adequate nutrition
Explanation
Explanation
The primary concern for patients undergoing radiation therapy to the head and neck area, particularly for conditions like laryngeal cancer, is maintaining adequate nutrition. Radiation often causes oral mucosal ulcerations, pain, and difficulty swallowing, which can significantly impact a patient's ability to eat and maintain proper nutrition. Ensuring that the patient receives adequate nutrition is essential to support their recovery, prevent malnutrition, and maintain strength during cancer treatment. The nurse should prioritize addressing the patient's nutritional needs and consider interventions such as enteral feeding, modified diets, or nutritional supplements。Correct Answer Is:
D. Adequate nutritionWhat symptoms does the nurse assess for in a patient suspected of having cardiac tamponade?
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Dyspnea, diaphoresis, and pericardial friction rub
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Dyspnea, tachycardia, and cyanosis
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Hypertension, muffled heart sounds, and cough
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Muffled heart sounds, pulsus paradoxus, and narrowed pulse pressure
Explanation
Explanation
Cardiac tamponade occurs when fluid accumulates in the pericardial sac, creating pressure on the heart and impairing its ability to pump effectively. The classic symptoms of cardiac tamponade include:- Muffled heart sounds due to the insulating effect of the fluid in the pericardium, making it harder to hear the heart sounds through the chest wall。
- Pulsus paradoxus, which is an abnormal decrease in systolic blood pressure (greater than 10 mmHg) during inspiration. It is a key diagnostic finding for cardiac tamponade。
- Narrowed pulse pressure, which is the difference between systolic and diastolic blood pressure, typically becomes smaller in tamponade due to the decreased ability of the heart to pump effectively。
Correct Answer Is:
D. Muffled heart sounds, pulsus paradoxus, and narrowed pulse pressureA patient in the ED suddenly becomes confused and has slurred speech and right-sided weakness. What is the nurse's priority action?
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Perform a full neurological assessment
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Reassure the patient and monitor vital signs
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Check the patient's blood glucose
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Notify the stroke team and prepare for a CT scan
Explanation
Explanation
The symptoms of sudden confusion, slurred speech, and right-sided weakness are suggestive of a potential stroke. The priority action is to immediately notify the stroke team and prepare for a CT scan of the brain to assess for ischemic or hemorrhagic stroke. Rapid intervention is critical in the management of stroke to restore blood flow (in ischemic stroke) or manage bleeding (in hemorrhagic stroke). Early recognition and treatment are key to minimizing brain damage and improving outcomes。Correct Answer Is:
D. Notify the stroke team and prepare for a CT scanPrescribed: Begin Nitroglycerine infusion at 20 mL/hr x 12 hours
Available: Nitroglycerine 100mg/250mL D5W
How many mcg/min the patient is receiving?
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132 mcg/min
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100 mcg/min
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160 mcg/min
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150 mcg/min
Explanation
Explanation
- First, determine the concentration of nitroglycerine:
- Available concentration: 100 mg in 250 mL。
- Therefore, concentration is:
100 mg ÷ 250 mL=0.4 mg/mL
- Available concentration: 100 mg in 250 mL。
- Convert the prescribed infusion rate from mL/hr to mL/min:
- The prescribed infusion rate is 20 mL/hr。
- Convert to mL/min:
20 mL/hr ÷ 60 min/hr=0.33 mL/min
- The prescribed infusion rate is 20 mL/hr。
- Calculate the amount of nitroglycerine delivered per minute in mg:
- Infusion rate: 0.33 mL/min
- Concentration: 0.4 mg/mL
- Therefore, the amount of nitroglycerine delivered per minute is:
0.33 mL/min×0.4 mg/mL=0.132 mg/min - Convert mg/min to mcg/min:
- Since 1 mg = 1000 mcg:
0.132 mg/min×1000=132 mcg/min - Final Answer: A. 132 mcg/min
The patient is receiving 132 mcg/min of nitroglycerine。
- Infusion rate: 0.33 mL/min
Correct Answer Is:
A. 132 mcg/minThe patient is receiving external beam radiation therapy and has skin markings left on the treatment area following treatment. Which is an appropriate nursing intervention?
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Notify the health care provider of the markings.
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Document the markings as radiation side effects.
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Cleanse the markings with alcohol.
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Leave the markings in place for further treatments.
Explanation
Explanation
Skin markings are typically made with special ink or a tattoo to precisely align the patient for each radiation treatment. These markings are essential for ensuring the correct area is targeted and that radiation is delivered to the precise location. The markings should be left in place and not removed until the full course of radiation therapy is completed, to ensure accurate positioning for subsequent treatments。Correct Answer Is:
D. Leave the markings in place for further treatments.While caring for a patient in shock, the nurse reviews arterial blood gas results. Which acid-base imbalance would indicate a deteriorating status and the progressive stage of shock?
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Metabolic acidosis
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Metabolic alkalosis
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Respiratory acidosis
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Respiratory alkalosis
Explanation
Explanation
In the progressive stage of shock, the body starts to experience impaired tissue perfusion and hypoxia, leading to anaerobic metabolism and an accumulation of lactic acid. This results in metabolic acidosis, which is characterized by a low pH and low bicarbonate (HCO3-) levels. As shock progresses, the body’s inability to clear acid builds up, worsening the condition and indicating a deteriorating status. Metabolic acidosis reflects the body’s failing compensatory mechanisms and is a critical sign of hypoperfusion and organ dysfunction。Correct Answer Is:
A. Metabolic acidosisA patient arrives in the emergency department after achieving return of spontaneous circulation (ROSC) following an out of hospital cardiac arrest. The provider orders initiation of Targeted Temperature Management (TTM). Which statement best describes the purpose of TTM?
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TTM is used to stabilize blood pressure by increasing metabolic demand.
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TTM is used to maintain a controlled target temperature of 89.6° F to 96.8°F to reduce secondary brain injury after cardiac arrest.
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TTM is used to rapidly raise the patient's body temperature to improve cardiac output after ROSC.
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TTM is used only to prevent fever and does not involve intentional cooling.
Explanation
Explanation
Targeted Temperature Management (TTM) is a therapeutic intervention used to cool the body to a controlled temperature range (usually 89.6° F to 96.8° F) after a cardiac arrest. The purpose of TTM is to reduce metabolic demand and prevent secondary brain injury caused by ischemic reperfusion and neurological damage that occurs after the return of spontaneous circulation (ROSC). Cooling the body helps to protect the brain from further damage and has been shown to improve neurological outcomes in patients after cardiac arrest。Correct Answer Is:
B. TTM is used to maintain a controlled target temperature of 89.6° F to 96.8°F to reduce secondary brain injury after cardiac arrest.A patient is being treated for shock. The nurse knows that shock is a clinical syndrome characterized by which physiologic state?
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Inadequate tissue perfusion
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Loss of blood
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Hypotension
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Severe infection
Explanation
Explanation
Shock is a clinical syndrome characterized by inadequate tissue perfusion, which leads to insufficient oxygen and nutrient delivery to the tissues. This can occur due to hypovolemia, cardiogenic failure, distributive causes (such as septic shock), or other conditions. The lack of proper perfusion can result in cellular dysfunction and, if untreated, can lead to organ failure and death. The priority in shock management is to restore adequate perfusion to tissues and organs to prevent irreversible damage。Correct Answer Is:
A. Inadequate tissue perfusionIt has been identified that the patient is in septic shock. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?
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Obtain a urine specimen
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Type and cross-match for 2 units of packed PRBs
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Obtain blood cultures
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Obtain a wound culture
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Rapidly administer 30mL/kg of normal saline
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Insert a nasogastric tube
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Measure lactate level
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Administer broad-spectrum antibiotics
Explanation
Explanation
Septic shock is a medical emergency that requires immediate and aggressive management to improve patient outcomes and prevent further complications. In the first hour of managing sepsis, the following actions should be taken:C. Obtain blood cultures
Blood cultures should be obtained before antibiotics are administered to identify the causative organism of the infection. This is essential for guiding targeted therapy once the culture results are available。
E. Rapidly administer 30mL/kg of normal saline
Fluid resuscitation is a key intervention in septic shock. Administering 30 mL/kg of normal saline rapidly helps to restore circulating blood volume, increase perfusion, and prevent further organ dysfunction. This should be done within the first hour。
G. Measure lactate level
Lactate levels are a key indicator of tissue hypoxia and metabolic stress in sepsis. Elevated lactate levels reflect poor tissue perfusion and can help assess the severity of sepsis and guide treatment。
H. Administer broad-spectrum antibiotics
Broad-spectrum antibiotics should be administered within the first hour of recognizing septic shock to target a wide range of potential pathogens. This is crucial to prevent the infection from worsening and to begin controlling the underlying infection。
Correct Answer Is:
C. Obtain blood cultures, E. Rapidly administer 30mL/kg of normal saline, G. Measure lactate level, H. Administer broad-spectrum antibioticsHow to Order
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