Deck 14: Overview of Shock and Sepsis

Question 1

The nurse has just completed the assessment of a patient admitted with a gunshot wound to the femoral artery.Which is the priority nursing diagnosis for this patient?

A) Ineffective Coping
B) Deficient Fluid Volume
C) Decreased Cardiac Output
D) Ineffective Airway Clearance

Answer 1

Decreased Cardiac Output

Question 2

A patient develops hypovolemic shock secondary to pancreatitis.Which action by the nurse is most appropriate?

A) Starting an 18-gauge intravenous catheter in the patient's nondominant hand
B) Ordering a type and cross-match of packed red blood cells
C) Preparing to assist with central line placement
D) Inserting a nasogastric tube

Answer 2

Preparing to assist with central line placement

Question 3

The nurse is providing care to a patient diagnosed with hypovolemic shock.Which nursing action is appropriate for this patient during the initial compensatory phase?

A) Placing a cool blanket over the patient
B) Raising the patient's head to a 30-degree angle
C) Positioning the patient in the left-lateral recumbent position
D) Turning the patient's head to one side if no neck injury is suspected

Answer 3

Turning the patient's head to one side if no neck injury is suspected

Question 4

A nurse working in the intensive care unit (ICU)is caring for a patient in refractory stage of shock.When planning care,which does the nurse anticipate?

A) A subtle change in heart rate
B) A change from aerobic to anaerobic metabolism
C) The development of hyperglycemia
D) The development of cardiac dysrhythmias

Question 5

During the initial stage of shock,which clinical manifestation should the nurse monitor for when assessing the patient?

A) Lethargy
B) Hypotension
C) Respiratory alkalosis
D) Subtle changes in heart rate

Question 6

A patient is prescribed epinephrine for the prevention of anaphylactic shock.The patient states,"I thought shock was about heart failure." Which response by the nurse is most appropriate?

A) "There are many kinds of shock that also include infection,nervous system damage,and loss of blood."
B) "Heart failure is the most serious kind of shock;others include infection,kidney failure,and loss of blood."
C) "There are many kinds of shock: heart failure,nervous system damage,loss of blood,and respiratory failure."
D) "Allergic response is the most fatal type of shock;other types involve loss of blood,heart failure,and liver failure."

Question 7

The nurse is conducting medication teaching for a patient who is prescribed an epi-pen.Which statements made by the patient indicates the need for additional instruction?

A) "I will carry an epi-pen with me at all times."
B) "I will check the expiration date on my epi-pen regularly."
C) "I should hold the epi-pen in place for 10 seconds after injection."
D) "I should use the epi-pen to inject the drug into my abdominal wall."

Question 8

The nurse is administering albumin 5% to a patient in shock.Which nursing action is appropriate when assessing this patient?

A) Auscultate breath sounds for crackles
B) Auscultate breath sounds for hyperresonance
C) Auscultate breath sounds for inspiratory stridor
D) Auscultate for an absence of breath sounds in the lower lobes

Question 9

The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a patient with septicemia.Which intervention will address this patient's health problem?

A) Monitor for cyanosis.
B) Monitor heart rate every hour.
C) Assess temperature every four hours.
D) Monitor pupil reactions every eight hours.

Question 10

A patient being treated for hypovolemic shock is prescribed a low dose of dopamine.Which outcome does the nurse anticipate for this patient?

A) Increased cardiac output
B) Stabilization of fluid loss
C) Urinary output of at least 30 mL/hour
D) Vasoconstriction and increased blood pressure

Question 11

The nurse explains the purpose of an infusion of albumin 5% to a patient recovering from hypovolemic shock.Which statement indicates that the patient understands the instructions?

A) "It is a protein that pulls water into my blood vessels."
B) "It is a protein that causes my kidneys to conserve fluid."
C) "It is a super-concentrated salt solution that helps me conserve body fluid."
D) "It is a liquid that has electrolytes in it to pull water into my blood vessels."

Question 12

The nurse is providing care to a patient admitted to the emergency department (ED)with a gunshot wound and profound blood loss.Which order does the nurse anticipate for this patient?

A) Normal saline
B) Dextrose in water
C) Packed red blood cells
D) Albumin

Question 13

A nurse is caring for a patient who was involved in a motor vehicle accident who has lost approximately 1,500 mL of blood.Based on this data,which type of shock is the patient experiencing?

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

Question 14

An older adult patient is experiencing hypovolemic shock.Which is the priority intervention for this patient?

A) Assessing the cause of bleeding
B) Providing replacement of volume
C) Establishing invasive cardiac monitoring
D) Administering analgesics for control of pain

Question 15

The nurse is preparing an educational session on sepsis.Which should the nurse include as a major risk factor for the development of this health problem?

A) Immunosuppression
B) Elevated temperature
C) Pneumococcal bacteria
D) Leukocytosis on the complete blood count

Question 16

The nurse is providing care to a patient who is admitted to the emergency department with symptoms of a myocardial infarction (MI).Which is the primary purpose of the interventions administered to this patient?

A) Providing pain relief
B) Preventing extension of damage
C) Preventing cardiogenic shock
D) Reducing blood pressure

Question 17

The nurse is preparing to administer diphenhydramine to a patient who is experiencing a severe allergic reaction to peanuts.Which information about the drug should the nurse provide to the patient?

A) "This is the medication of choice to treat airway obstruction."
B) "This medication will help relieve your itching and runny nose."
C) "This medication will prevent you from going into anaphylactic shock."
D) "This medication will take a while to be effective but will control your symptoms for several hours."

Question 18

The nurse is providing care for a patient receiving treatment for cardiogenic shock.Which assessment finding indicates that the compensatory mechanism of vasoconstriction has occurred in this patient?

A) Increased heart rate
B) Increased injection fraction
C) Decreased urine output
D) Decreased temperature

Question 19

The nurse is providing care to a patient who is admitted with cardiogenic shock.The nurse administers the prescribed atropine with no results.Which prescription does the nurse anticipate from the health-care provider based on this data?

A) A beta blocker
B) Transcutaneous pacing
C) Cardiac defibrillation
D) A preload reducer

Question 20

An older adult patient is recovering in the intensive care unit (ICU)from septicemia.Which intervention will help prevent further infection for this patient?

A) Provide oral and skin care
B) Implement sterile wound care
C) Encourage turn,cough,and deep breathe every shift.
D) Place the Foley drainage on the bed at the patient's feet

Question 21

Which is the highest priority nursing action when providing care to a patient with shock?

A) Starting two large intravenous catheters
B) Recognizing early clinical manifestations
C) Administering high-flow oxygen
D) Calling for help immediately

Question 22

A patient in neurogenic shock is receiving rapid intravenous fluids.Which assessment finding indicates the need for additional nursing interventions?

A) The patient's mean arterial pressure (MAP)is 60 mmHg.
B) The patient is unconscious.
C) The patient has received two liters of infused fluid.
D) The patient is perspiring heavily.

Question 23

The nurse is providing care to a patient admitted with a spinal cord injury.The patient is bradycardic,hypotensive,and has cold and clammy skin.Which is the priority nursing action for this patient?

A) Starting two large intravenous catheters
B) Notifying the Rapid Response Team
C) Calling the patient's physician to report the changes
D) Placing oxygen on the patient