Deck 69: Nursing Management Shock

Question 1

The nurse is caring for a client in the emergency department with massive trauma and possible spinal cord injury. Which of the following findings by the nurse will help confirm a diagnosis of neurogenic shock?

A)Cool, clammy skin
B)Inspiratory crackles
C)Apical heart rate 48 beats/minute
D)Temperature 38.4C (101.1F)

Answer 1

Apical heart rate 48 beats/minute

Question 2

The nurse is caring for a client in the emergency department (ED) who is in shock of unknown etiology. Which of the following actions should the nurse implement first?

A)Administer oxygen
B)Attach a cardiac monitor
C)Obtain the blood pressure
D)Check the level of consciousness

Answer 2

Administer oxygen

Question 3

A client who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of the following prescribed interventions should the nurse implement first?

A)Place the client on continuous cardiac monitor.
B)Draw blood to type and crossmatch for transfusions.
C)Insert two 14-gauge IV catheters in antecubital space.
D)Administer oxygen at 100% per non-rebreather mask.

Answer 3

Administer oxygen at 100% per non-rebreather mask.

Question 4

The nurse is caring for a client with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which of the following prescribed interventions should the nurse question?

A)Infuse normal saline at 250 mL/hour.
B)Keep head of bed elevated to 30 degrees.
C)Give nitroprusside unless systolic BP <90 mm Hg.
D)Administer dobutamine to keep systolic BP >90 mm Hg.

Question 5

The nurse is assessing a client who is receiving a nitroprusside infusion to treat cardiogenic shock. Which of the following findings indicates that the medication is effective?

A)No heart murmur is audible.
B)Skin is warm and dry.
C)Troponin level is decreased.
D)Blood pressure is 90/40 mm Hg.

Question 6

The charge nurse is evaluating the skills of a new RN caring for a client in shock. Which of the following actions by the new RN indicates a need for more education in the care of clients with shock?

A)Placing the pulse oximeter on the ear for a client with septic shock
B)Keeping the head of the bed flat for a client with hypovolemic shock
C)Decreasing the room temperature to 20°C (68°F) for a client with neurogenic shock
D)Increasing the nitroprusside infusion rate for a client with a high SVR

Question 7

The nurse is caring for a client with noncardiogenic shock who is cool, clammy and whose hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which of the following actions should the nurse anticipate implementing?

A)Increase the rate for the prescribed dopamine infusion.
B)Decrease the rate for the prescribed nitroglycerin infusion.
C)Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion.
D)Increase the rate for the prescribed sodium nitroprusside infusion.

Question 8

After receiving 1 000 mL of normal saline, the central venous pressure for a client who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. Which of the following prescribed medications should the nurse administer?

A)Nitroglycerin
B)Drotrecogin-?
C)Norepinephrine
D)Sodium nitroprusside

Question 9

The nurse is caring for a client with cardiogenic shock and pulmonary edema who has the following vital signs: BP 86/50, pulse 126, respirations 30. Which of the following actions should the nurse anticipate implementing?

A)Infusion of 5% human albumin
B)Administration of furosemide IV
C)Titration of an epinephrine drip
D)Administration of hydrocortisone

Question 10

Which of the following assessments is most important for the nurse to make in order to evaluate whether treatment of a client with anaphylactic shock has been effective?

A)Pulse rate
B)Orientation
C)Blood pressure
D)Oxygen saturation

Question 11

Which of the following information obtained by the nurse when caring for a client who has cardiogenic shock indicates that the client may be developing multiple organ dysfunction syndrome (MODS)?

A)The client's serum creatinine level is elevated.
B)The client complains of intermittent chest pressure.
C)The client has crackles throughout both lung fields.
D)The client's extremities are cool and pulses are weak.

Question 12

The nurse is caring for a client with septic shock who has had a urine output of 20 mL/hour for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of the following orders by the healthcare provider should the nurse question?

A)Administer furosemide 40 mg IV.
B)Increase normal saline infusion to 150 mL/hour.
C)Administer hydrocortisone 100 mg IV.
D)Administer dopamine 5 mcg/kg/minute IV.

Question 13

The emergency department (ED) receives notification that a client who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. Which of the following should the nurse obtain in preparation for the client's arrival?

A)500 mL of 5% albumin
B)Lactated Ringer's solution
C)Two 14-gauge IV catheters
D)Dopamine infusion

Question 14

The nurse is caring for a client who has septic shock. Which of the following assessment findings is most important for the nurse to report to the health care provider?

A)BP 92/56 mm Hg
B)Skin cool and clammy
C)Apical pulse 118 beats/minute
D)Arterial oxygen saturation 91%

Question 15

Norepinephrine has been prescribed for a client who was admitted with dehydration and hypotension. Which of the following client information indicates that the nurse should consult with the health care provider before administration of the norepinephrine?

A)The client's central venous pressure is 3 mm Hg.
B)The client is receiving low dose dopamine.
C)The client is in sinus tachycardia at 100-110 beats/minute.
D)The client has had no urine output since being admitted.

Question 16

Which of the following interventions should the nurse include in the plan of care for a client who has cardiogenic shock?

A)Avoid elevating head of bed.
B)Check temperature every 2 hours.
C)Monitor breath sounds frequently.
D)Assess skin for flushing and itching.

Question 17

Which of the following assessments should the nurse make to evaluate the effectiveness of omeprazole administration to a client with systemic inflammatory response syndrome (SIRS)?

A)Auscultate bowel sounds.
B)Ask the client about nausea.
C)Monitor stools for occult blood.
D)Check for abdominal distention.

Question 18

During change-of-shift report, the nurse learns that a client has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which of the following findings is most important for the nurse to report to the health careprovider?

A)Decreased bowel sounds
B)Apical pulse 110 beats/minute
C)Pale, cool, and dry extremities
D)New onset of confusion and agitation

Question 19

The nurse is caring for a client with septic shock who has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 40°C (104°F), and blood glucose 13.7 mmol/L. Which of the following prescribed interventions will the nurse implement first?

A)Give normal saline IV at 500 mL/hour.
B)Infuse Drotrecogin-? 24 mcg/kg.
C)Start insulin drip to maintain blood glucose at 11-15 mmol/L.
D)Titrate norepinephrine to keep mean arterial pressure (MAP) at 65-70 mm Hg.

Question 20

Which of the following findings is the best indicator that the fluid resuscitation for a client with hypovolemic shock has been successful?

A)Hemoglobin is within normal limits.
B)Urine output is 60 mL over the last hour.
C)Pulmonary artery occlusive pressure (PAOP) is normal.
D)Mean arterial pressure (MAP) is 65 mm Hg.

Question 21

The following therapies are prescribed by the health care provider for a client who has respiratory distress and syncope after a bee sting. Which of the following actions should the nurse implement first?

A)Normal saline infusion
B)Epinephrine
C)Dexamethasone
D)Diphenhydramine

Question 22

The health care provider prescribes the following actions for a client who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions?

A)Obtain blood and urine cultures.
B)Give vancomycin 1 g IV.
C)Infuse vasopressin 0.01 units/minute.
D)Administer normal saline 1 000 mL over 30 minutes.
E)Titrate oxygen administration to keep O? saturation >95%.

Question 23

The nurse is caring for a client with neurogenic shock who is receiving a phenylephrine infusion through a left forearm IV. Which of the following assessment information obtained by the nurse indicates a need for immediate action?

A)The client's IV infusion site is cool and pale.
B)The client has warm, dry skin on the extremities.
C)The client has an apical pulse rate of 58 beats/minute.
D)The client's urine output has been 28 mL over the last hour.

Question 24

The nurse is caring for a client who is receiving vasopressin to treat septic shock. Which of the following assessments is most important for the nurse to communicate to the health care provider?

A)The client's heart rate is 108 beats/minute.
B)The client is complaining of chest pain.
C)The client's peripheral pulses are weak.
D)The client's urine output is 15 mL/hour.

Question 25

The nurse is caring for a client with neurogenic shock that has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take? (Select all that apply.)

A)Prepare to administer atropine IV.
B)Obtain baseline body temperature.
C)Prepare for intubation and mechanical ventilation.
D)Administer large volumes of lactated Ringer's solution.
E)Administer high-flow oxygen (100%) by non-rebreather mask.