Practice Quiz

CEN Practice Exam (Certified Emergency Nurse)

Category - Shock

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An elderly patient comes into the emergency department to rule out stroke. On admission, vital signs are pulse 90, blood pressure 150/100 and respirations 20. Upon reassessment 30 minutes later, vital signs are pulse 78, blood pressure 170/90 and respirations 24 and irregular. What should be the nurse’s first priority?
  1. Have the patient describe how they are feeling.
  2. Check the patient’s Dilantin level.
  3. Decrease fluids.
  4. Encourage the patient to drink.
Explanation
Answer: C - The nurse should decrease the fluids based on this assessment. The patient is showing signs of hypervolemia and increased intracranial pressure. The other three options are inappropriate for a patient who is be monitored for a stroke.
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