Question 1

A client is in the early stages of shock and is restless.What comfort measures does the nurse delegate to the nursing student? (Select all that apply.)

Accepted Answer

The student can bring the client warm blankets,reorient the client as needed to decrease anxiety,and sit with the client for reassurance.The client should be NPO at this point,so hot tea is prohibited.Massaging the legs is not recommended as this can dislodge any clots present,which may lead to pulmonary embolism.

Question 2

A client is receiving norepinephrine (Levophed)for shock.What assessment finding best indicates a therapeutic effect from this drug?

Accepted Answer

Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine.The brain is very sensitive to changes in oxygenation and perfusion.Norepinephrine can cause chest pain as an adverse reaction,so the absence of chest pain does not indicate therapeutic effect.The IV site is normal.The urine output is normal,but only minimally so.

Question 3

A nurse works at a community center for older adults.What self-management measure can the nurse teach the clients to prevent shock?

Accepted Answer

Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration.Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst).Telling clients not to get dehydrated is important,but not the best answer because it doesn't give them the tools to prevent it from occurring.Older adults should seek attention for lacerations,but this is not as important an issue as staying hydrated.Taking medications as prescribed may or may not be related to hydration.

Question 4

A nurse is caring for a client after surgery.The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago.What action by the nurse is best?

Accepted Answer

Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate,respiratory rate,or blood pressure.Even though these readings are not out of the normal range,the nurse should conduct a thorough assessment of the client,focusing on indicators of perfusion.The client may need pain medication,but this is not the priority at this time.Documentation should be done thoroughly but is not the priority either.The nurse should not increase the rate of the IV infusion without an order.

Question 5

A client in shock is apprehensive and slightly confused.What action by the nurse is best?

Accepted Answer

The nurse's presence will be best to reassure this client.Antianxiety medication is not warranted as this will lower the client's blood pressure.Using all four siderails on a hospital bed is considered a restraint in most facilities,although the nurse should ensure the client's safety.Telling a confused client that everything is being done is not the most helpful response.

Question 6

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL.The spouse asks why the client needs insulin as the client is not a diabetic.What response by the nurse is best?

Accepted Answer

High glucose readings are common in shock,and best outcomes are the result of treating them and maintaining glucose readings in the normal range.Medications and IV solutions may raise blood glucose levels,but this is not the most accurate answer.The stress of the illness has not "made" the client diabetic.

Question 7

A client has been brought to the emergency department after being shot multiple times.What action should the nurse perform first?

Accepted Answer

The nurse's priority is to care for the client.Since the client has gunshot wounds and is bleeding,the nurse applies personal protective equipment (i.e.,gloves)prior to care.This takes priority over calling law enforcement.Requesting blood bank products can be delegated.The nurse may or may not have to prepare the client for emergency surgery.

Question 8

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.)

Accepted Answer

Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring.Proper hand hygiene,using aseptic technique,and removing IV lines and catheters are also important actions to prevent shock.Monitoring laboratory values does not prevent shock but can indicate a change.

Question 9

The nurse gets the hand-off report on four clients.Which client should the nurse assess first?

Accepted Answer

This client has a falling systolic blood pressure,rising diastolic blood pressure,and narrowing pulse pressure,all of which may be indications of the progressive stage of shock.The nurse should assess this client first.The client with the unchanged oxygen saturation is stable at this point.Although the client with a change in pulse has a slower rate,it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety has been relieved,or he or she is sleeping or relaxing.A urine output of 40 mL/hr is only slightly above the normal range,which is 30 mL/hr.

Question 10

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.)

Accepted Answer

The common manifestations of shock,no matter the cause,are directly related to the effects of anaerobic metabolism and hypotension.Hyperglycemia,impaired renal function,and increased perfusion are not manifestations of shock.

Question 11

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride)via IV infusion.What action by the student causes the registered nurse to intervene?

Accepted Answer

Nitroprusside degrades in the presence of light,so it must be protected by leaving it in the original brown plastic bag when infusing.The other actions are correct,although a "smart" pump is not necessarily required if the facility does not have them available.The drug must be administered via an IV pump,although the programmable pump is preferred for safety.

Question 12

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm³,blood glucose level 198 mg/dL,and temperature 96.2° F (35.6° C).What action by the nurse takes priority?

Accepted Answer

This client has several indicators of sepsis with systemic inflammatory response.The nurse should notify the health care provider immediately.Documentation needs to be thorough but does not take priority.The client may appreciate warm blankets,but comfort measures do not take priority.The client may or may not need insulin.

Question 13

A client arrives in the emergency department after being in a car crash with fatalities.The client has a nearly amputated leg that is bleeding profusely.What action by the nurse takes priority?

Accepted Answer

Airway is the priority,followed by breathing and circulation (IVs and direct pressure).Obtaining consent is done by the physician.

Question 14

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery.The client's sternal wound has not yet healed.What statement by the client most indicates a higher risk of developing sepsis after discharge?

Accepted Answer

All these statements indicate a potential for leading to infection once the client gets back home.A large party might include individuals who are themselves ill and contagious.Having litter boxes in the home can expose the client to microbes that can lead to infection.Small children often have upper respiratory infections and poor hand hygiene that spread germs.However,the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

Question 15

A client in shock has been started on dopamine.What assessment finding requires the nurse to communicate with the provider immediately?

Accepted Answer

Chest heaviness or pain indicates myocardial ischemia,a possible adverse effect of dopamine.While taking dopamine,the oxygen requirements of the heart are increased due to increased myocardial workload,and may cause ischemia.Without knowing the client's previous blood pressure or pedal pulses,there is not enough information to determine if these are an improvement or not.A urine output of 32 mL/hr is acceptable.

Question 16

A student is caring for a client who suffered massive blood loss after trauma.How does the student correlate the blood loss with the client's mean arterial pressure (MAP)?

Accepted Answer

Lower blood volume will decrease MAP.The other answers are not accurate.

Question 17

The nurse is caring for a client with suspected severe sepsis.What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.)

Accepted Answer

Within the first 3 hours of suspecting severe sepsis,the nurse should draw (or facilitate)serum lactate levels,obtain blood cultures (or other cultures),and administer antibiotics (after the cultures have been obtained).Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

Question 18

A nurse is caring for several clients at risk for shock.Which laboratory value requires the nurse to communicate with the health care provider?

Accepted Answer

A lactate level of 6 mmol/L is high and is indicative of possible shock.A creatinine level of 0.9 mg/dL is normal.A sodium level of 150 mEq/L is high,but that is not related directly to shock.A white blood cell count of 11,000/mm³ is slightly high but is not as critical as the lactate level.

Question 19

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock.For what factors would the nurse assess? (Select all that apply.)

Accepted Answer

Immobility,decreased thirst response,diminished immune response,and malnutrition can place the older adult at higher risk of developing shock.Overhydration is not a common risk factor for shock.

Question 20

A nurse is caring for a client after surgery who is restless and apprehensive.The unlicensed assistive personnel (UAP)reports the vital signs and the nurse sees they are only slightly different from previous readings.What action does the nurse delegate next to the UAP?

Accepted Answer

Urine output changes are a sensitive early indicator of shock.The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements.The UAP cannot assess for pain.Repositioning may or may not be effective for decreasing restlessness,but does not take priority over physical assessments.Reassurance is a therapeutic nursing action,but the nurse needs to do more in this situation.

Quiz 37: Care of Patients with Shock