Practice Quiz

NCLEX-RN Exam Practice

Category - Shock

Start a Study Session Sign up for Question of the Day

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. An IV is run for the patient. Upon reassessment 30 minutes later, vital signs are pulse 78, blood pressure 170/90, and respirations 24 and irregular. What action should the nurse consider taking?

  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.

Previous Next
Was this helpful? Upvote!
Login to contribute your own answer or details
Start a Study Session Sign up for Question of the Day

Top questions

Related questions

Most popular on PracticeQuiz