Deck 9: Nursing Care of Patients in Shock

Question 1

The nurse can expect a patient who lost 2 liters of blood during surgery to experience which type of shock?

A)Cardiogenic
B)Anaphylactic
C)Hypovolemic
D)Obstructive

Answer 1

Hypovolemic

Question 2

The nurse is reviewing orders for a patient in anaphylactic shock. Which medication should the nurse plan to administer first?

A)Dobutamine (Dobutrex) 2.0.9% normal saline
B)Epinephrine (Adrenalin)
C)Dexamethasone (Decadron)

Answer 2

Epinephrine (Adrenalin)

Question 3

The nurse knows early in shock, blood is shunted away from the kidneys. How long can the kidneys tolerate reduced blood flow before cells begin to die?

A)1 hour
B)2 hours
C)3 hours
D)4 hours

Answer 3

1 hour

Question 4

The nurse is caring for a group of patients. Which patient is at high risk for developing obstructive shock?

A)A patient with a wound that won't heal
B)A patient with myocarditis
C)A patient who lost 500 mL of blood during surgery
D)A patient with a tension pneumothorax

Question 5

Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical intervention stops the bleeding and the shock stabilizes. Which finding should the nurse act on immediately?

A)The blood pH is 7.36.
B)Bowel sounds are hypoactive.
C)Urinary output is 15 mL/hr.
D)Pupils are equally reactive to light.

Question 6

A patient with a history of a myocardial infarction has chest pain. The patient's skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take?

A)Place the patient supine.
B)Notify the charge nurse.
C)Check the urine specific gravity.
D)Infuse 0.9% NS wide open.

Question 7

The nurse is caring for a group of patients. Which patient is at high risk for developing sepsis?

A)A 20-year-old marathon runner with allergies
B)A 25-year-old banker with HIV
C)A 30-year-old construction worker with bipolar disorder
D)A 35-year-old teacher with fibromyalgia

Question 8

A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160 beats/minute, and respirations 30/minute. The patient is receiving IV fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the most likely cause of the patient's respiratory rate?

A)Electrolyte imbalances
B)Inadequate tissue perfusion
C)Rapid rate of fluid replacement
D)Reaction to the blood transfusion

Question 9

A patient in shock is diagnosed with metabolic acidosis. What should the nurse realize as being the mechanism behind the development of this acid-base imbalance?

A)Excessive aerobic metabolism
B)Excessive anaerobic metabolism
C)Decreased anaerobic metabolism
D)Release of cortisol and glucagon

Question 10

The nurse has been informed a patient suffered injury to the liver caused by ischemia. What can the nurse expect to find?

A)Decreased bilirubin levels
B)Elevated ammonia levels
C)Decreased liver enzymes
D)Increased plasma proteins

Question 11

On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive, confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the nurse do first?

A)Cover the patient with warm blankets.
B)Perform a rapid head-to-toe assessment.
C)Obtain the patient's medical history from family.
D)Reorient the patient to person, place, and time.

Question 12

The nurse is receiving report on patients assigned for the next shift. Which patient should the nurse observe first?

A)A patient who has a pressure ulcer who is due for a dressing change
B)A patient with diabetes who has a blood sugar level of 85 and is eating lunch
C)A patient with cellulitis who is receiving the first dose of IV antibiotics and who is reporting a feeling of tightness in the throat
D)A patient with sickle cell anemia who is receiving a monthly transfusion of a unit of packed red blood cells who is reporting left knee pain

Question 13

The nurse is caring for a patient in mild shock. Which medication should the nurse question before providing if ordered for a patient experiencing shock?

A)Benadryl
B)Morphine
C)Dopamine
D)Solu-Medrol

Question 14

The unlicensed assistive personnel (UAP) reports the following to the nurse. Which patient should the nurse see first based on this information?

A)A patient with a blood pressure of 110/74 mm Hg
B)A patient with respirations of 36 breaths/min
C)A patient with a heart rate of 78 beats/min
D)A patient with a urine output of 120 mL over 3 hours

Question 15

A patient with progressive shock is diaphoretic and confused. The most recent blood pressure measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. IV fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output?

A)Encourage oral fluids.
B)Irrigate urinary catheter.
C)Increase IV fluid infusion rate.
D)Check urinary catheter for kinking.

Question 16

A patient with gastrointestinal bleeding is awake, alert, and oriented and has the following vital sign measurements: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock?

A)Respirations 18/min
B)Heart rate 118 beats/min
C)Temperature 98.6°F (37°C)
D)Blood pressure 130/90 mm Hg

Question 17

The nurse is assessing a patient who received 3 liters of normal saline for treatment of shock. Which finding indicates effectiveness of treatment?

A)Cool, clammy skin
B)Decreased urine output
C)Increased blood pressure
D)Increased heart rate

Question 18

The nurse is caring for a patient in septic shock. The nurse identifies which as the contributing factor?

A)Blood loss
B)Hypersensitivity reaction
C)Infection
D)Heart failure

Question 19

A patient asks the nurse what happens during shock. Which response by the nurse is accurate?

A)"The respiratory rate increases to deliver oxygen to the tissues."
B)"Heart rate decreases to prevent the heart from working hard."
C)"Epinephrine, cortisol, and glucagon decrease blood glucose levels to decrease cell fuel."
D)"Renin-angiotensin-aldosterone system leads to vasodilation and loss of sodium."

Question 20

Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday, report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which order should the nurse question?

A)Electrocardiogram (ECG) STAT
B)500 mL 0.9% normal saline (NS) over 30 minutes
C)Oxygen 2 L/min via nasal cannula
D)Arterial blood gases (ABGs) STAT and repeat in 1 hour

Question 21

The nurse is caring for a group of patients. Which patients are at highest risk for developing cardiogenic shock? (Select all that apply.)

A)A patient with myocarditis
B)A patient with cardiomyopathy
C)A patient with A-fib
D)A patient with an allergy to bees
E)A patient who has heatstroke

Question 22

The nurse is caring for an 85-year-old patient with septic shock. What should the nurse keep in mind when repositioning this patient?

A)Change positions slowly.
B)Reduce flow rate of oxygen.
C)Increase flow rate of IV fluids.
D)Place in Trendelenburg position.

Question 23

The nurse is preparing to administer 1 liter of 0.9% NS over 2 hours intravenously to a patient experiencing shock. At what rate will the nurse set the infusion pump? Enter the numeral only.

Question 24

The nurse is caring for a patient with stroke. Which does the nurse identify as complications of this condition? (Select all that apply.)

A)Acute respiratory distress syndrome (ARDS)
B)Cancer
C)Diabetes
D)Disseminated intravascular coagulation (DIC)
E)Multiple organ dysfunction syndrome (MODS)

Question 25

The nurse is teaching a patient how to administer epinephrine 0.5 mg intramuscularly. The available dose is 0.5 mg/0.5 mL. How many mL will the patient be taught to administer? Enter the numeral only.

Question 26

A patient who weighs 84 kg is prescribed dobutamine (Dobutrex) 0.5 mcg/kg. How many mcg will this patient receive? Enter the numeral only.

Question 27

A patient is developing anaphylactic shock. What should the nurse expect to observe in this patient? (Select all that apply.)

A)Polyuria
B)Urticaria
C)Bronchospasm
D)Muscle cramps
E)Laryngeal edema

Question 28

A patient in shock is being transported to the nearest emergency department. Upon arrival, in which order should the nurse provide care? Place the actions in the order that they should be performed from 1 to 6. ___

A) Ensure breathing. ___
B) Secure an airway. ___
C) Assess level of consciousness. ___
D) Prepare for x-rays and other tests. ___
E) Apply pressure to bleeding wounds. ___
F) Monitor heart rate and blood pressure.

Question 29

The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.)

A)Urinalysis
B)Chest x-ray
C)ABG
D)CBC
E)Electroencephalogram (EEG)
F)Blood type and crossmatch

Question 30

A patient in shock is found unresponsive. The nurse knows that immediate cardiopulmonary resuscitation is required because brain cells begin to die if deprived of oxygen for how many minutes? 1.1

A)2
B)4
C)8