Deck 9: Nursing Care of Patients in Shock

Question 1

On arrival in the emergency department, a patient who was in a motor vehicle accident is reported to be apprehensive, confused, hypotensive, tachycardic, and oliguric, with cool and clammy skin. What should the nurse do first?

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

Answer 1

Perform a rapid head-to-toe assessment.

Question 2

A patient presents with findings of anaphylactic shock. Which of the following nursing actions is the first priority?

A)Provide patient teaching.
B)Ensure a patent airway.
C)Obtain a detailed patient history.
D)Provide pain relief.

Answer 2

Ensure a patent airway.

Question 3

A patient with gastrointestinal bleeding has a hemoglobin of 8.5 g/dL. As the nurse assists the patient, who is anxious and irritable, the patient's nasogastric drainage becomes bright red, pulse 130 beats/minute, blood pressure 105/55 mm Hg, respirations 28/minute. The nurse recognizes which of the following is likely responsible for the changes in the patient's vital signs?

A)Early shock
B)Patient anxiety
C)Progressive shock
D)Parasympathetic response

Answer 3

Early shock

Question 4

A patient presents with suspected septic shock. Which of the following actions should the nurse take first?

A)Reassure the patient that everything possible will be done.
B)Insert an angiocath.
C)Obtain patient temperature.
D)Determine if the patient has any medication allergies.

Question 5

Despite aggressive treatment, the condition of a patient who is in shock continues to worsen. Surgical intervention stops the bleeding, and the shock stabilizes. Which of the following findings would require immediate action by the nurse?

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

Question 6

The nurse discovers a patient who is experiencing respiratory distress and mild shock. In which of the following positions should the patient be placed?

A)Semi-Fowler's position
B)High Fowler's position
C)Flat with elevated foot of bed
D)Trendelenburg position

Question 7

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 of these orders should the nurse question?

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

Question 8

The patient is started on a dopamine infusion for shock. The nurse would expect to see which of the following findings due to the dopamine?

A)Increased respiratory rate
B)Increased blood pressure
C)Decreased heart rate
D)Pain relief

Question 9

After an episode of shock, a patient's laboratory results reveal elevated serum levels of ammonia and bilirubin and decreased plasma proteins and clotting factors. The nurse recognizes that these abnormalities indicate damage to which of these organs?

A)Heart
B)Intestines
C)Kidneys
D)Liver

Question 10

The nurse is caring for a patient in mild shock. Which of the following medications should the nurse question if ordered for a patient experiencing shock?

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

Question 11

A patient who is found hemorrhaging from an incision has a blood pressure of 70/0 mm Hg. What type of fluid replacement does the nurse anticipate will be ordered initially?

A)Fresh frozen plasma
B)Packed red blood cells
C)0.9 % normal saline
D)Lactated Ringer's with 50 mL albumin

Question 12

A patient's family asks the nurse what shock is. Which of the following statements by the nurse would be most appropriate?

A)"It is a profound circulatory collapse."
B)"There is inadequate oxygen delivered to the tissues."
C)"It is the result of overwhelming emotion."
D)"It is caused by massive blood loss."

Question 13

Data collection findings for a patient involved in a motor vehicle accident include pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which of these does the nurse recognize as the likely cause of this acidosis?

A)Inadequate ventilation
B)Hyperventilation
C)Aerobic metabolism
D)Anaerobic metabolism

Question 14

A patient who had vascular leg surgery is found standing in a large pool of blood flowing from the surgical site. The patient is assisted into bed and is found to be pale with a palpable pulse. What action should the nurse take?

A)Apply oxygen at 2 L/min via nasal cannula.
B)Elevate legs and apply pressure over the bleeding site.
C)Start an infusion of 0.9% NaCl.
D)Notify the registered nurse.

Question 15

The nurse is caring for a patient who has hypovolemic shock and oliguria due to hemorrhage. The nurse recognizes that which of the following is the most likely cause of the patient's oliguria?

A)Inadequate oral fluid intake
B)Secretion of aldosterone
C)End-stage renal failure
D)Obstructed urinary catheter

Question 16

A patient experiencing progressive shock is diaphoretic, is confused, has a blood pressure of 82/40 mm Hg, and has a urinary catheter output of 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output?

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

Question 17

A patient who has gastrointestinal bleeding is awake, alert, and oriented. The patient's vital signs are: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C). Which of this patient's data collection findings should the nurse consider as a possible sign of early shock?

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

Question 18

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 intravenous fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. Which of the following does the nurse recognize as the most likely cause of the patient's respiratory rate?

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

Question 19

The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a patient who is experiencing shock. Which of the following benefits do these measures provide?

A)Decreased fluid volume
B)Increased fluid volume
C)Decreased oxygen demand
D)Increased oxygen demand

Question 20

After an episode of shock, a patient's laboratory results reveal decreased clotting factors. Based on these laboratory results, the nurse monitors for signs of which complication of shock?

A)Brain attack
B)Disseminated intravascular coagulation
C)Multisystem organ failure
D)Adult respiratory distress syndrome

Question 21

As part of ongoing data collection and care of a patient in shock, the nurse notes a slowing heart rate, systolic blood pressure less than 60 mm Hg, a decreasing temperature, decreasing respiration rate, and scant urine output. These signs and symptoms indicate to the nurse that the patient is in which stage of shock?

A)Mild
B)Compensated
C)Moderate
D)Severe

Question 22

The nurse is caring for a patient in shock and explains procedures and treatment to the patient. The nurse provides these explanations for which of the following reasons? (Select all that apply.?

A)To reduce the signs of shock
B)To provide support
C)Prevent future shock episodes
D)Knowledge decreases anxiety

Question 23

The nurse would recognize cardiogenic shock from other types of shock by the data collection findings for which of the following?

A)Bronchospasm
B)Oliguria
C)Pulmonary edema
D)Tachypnea

Question 24

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)Infuse 0.9% normal saline wide open.
C)Notify the registered nurse.
D)Check the urine specific gravity.

Question 25

Which one of the following nursing diagnoses would be most appropriate for the nurse to recommend be included in the patient's plan of care for a patient in shock?

A)Excess fluid volume
B)Hopelessness
C)Inadequate tissue perfusion
D)Risk for aspiration

Question 26

The nurse is contributing to a staff education program about complications associated with urinary catheters. Which of the following types of shock should the nurse recommend be included in the presentation?

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

Question 27

Which of the following signs and symptoms would the nurse expect to see for a patient going into anaphylactic shock? (Select all that apply.?

A)Urticaria
B)Polyuria
C)Laryngeal edema
D)Bronchospasm

Question 28

Which of the following occurs as the body's sympathetic nervous system responds to falling blood pressure? (Select all that apply.?

A)Blood is shunted away from the skin, kidneys, and intestines.
B)Vasodilation leads to increased fluid loss.
C)Blood glucose levels increase.
D)Sodium and water are retained.
E)Less oxygen is delivered to tissues.
F)Epinephrine is released from the adrenal medulla.

Question 29

The nurse is monitoring a patient who has been treated for several days for septic shock after surgery. Which of the following findings indicate that the patient is improving? (Select all that apply.?

A)Urine output less than 25 mL/hr
B)SpO₂ 94%
C)Blood pressure 110/90 mm Hg
D)Pulse 75 beats/minute
E)Temperature 101°F (38.3°C)
F)pH is 7.33

Question 30

The nurse receives an assignment of patients. Which of the following patients should the nurse observe first?

A)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
B)A patient with diabetes who has a blood sugar of 85 and is eating lunch
C)A patient with cellulitis who is receiving the first dose of intravenous antibiotics and who is reporting a feeling of tightness in the throat
D)A patient who has a pressure ulcer who is due for a dressing change
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 31

The nurse obtains vital signs on a patient with gastrointestinal bleeding who has a large, dark red, foul-smelling stool. Which of these vital sign changes should the nurse report as indicative of early shock?

A)Decreasing systolic blood pressure, bradycardia, and slow respirations
B)Rise in diastolic blood pressure, bradycardia, and slow respirations
C)Drop in diastolic blood pressure, bradycardia, and shallow respirations
D)Normal blood pressure, tachycardia, and rapid respirations

Question 32

The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which of the following diagnostic tests would the nurse expect? (Select all that apply.?

A)Complete blood count
B)Chest x-ray
C)Electroencephalogram (EEG)
D)Blood type and crossmatch
E)Arterial blood gas
F)Urinalysis

Question 33

A patient is transferred to the intensive care unit in neurogenic shock. The patient's wife asks what is happening. Which of these responses should the nurse give?

A)"Your husband's heart has failed as a pump that moves blood around the body."
B)"Your husband's blood vessels have dilated and lowered his blood pressure."
C)"Your husband has decreased circulating blood volume."
D)"Your husband is having an allergic reaction."

Question 34

The metabolic acidosis of shock is caused by which of these mechanisms?

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

Question 35

The nurse is monitoring a patient who has been in prolonged shock. For which of the following serious complications would the nurse observe to report? (Select all that apply.?

A)Malnutrition
B)Adult respiratory distress syndrome
C)Diabetes mellitus
D)Multiple organ dysfunction syndrome
E)Cerebrovascular accident
F)Sepsis
Completion
Complete each statement.

Question 36

A patient who had surgery 3 days ago has a temperature of 98°F (36.6°C), blood pressure 82/72 mm Hg, pulse 120 beats/minute, and respirations 30/minute. Which of these types of shock does the nurse recognize is likely occurring?

A)Cardiogenic
B)Hypovolemic
C)Neurogenic
D)Septic

Question 37

The nurse would recognize anaphylactic, septic, and neurogenic shock as examples of what type of shock?

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

Question 38

The nurse discovers a patient after surgery who is hemorrhaging from the incisional site. What is the most important action the nurse should take?

A)Apply pressure to the bleeding site.
B)Offer oral fluids.
C)Warm the patient.
D)Relieve the patient's apprehension.

Question 39

The nurse is caring for a patient experiencing shock who is taking Atenolol (Tenormin). Which of the following symptoms of shock would be expected to be present in this patient? (Select all that apply.?

A)Pulse 115 beats per minute
B)Respirations 28 per minute
C)Blood pressure 88/48 mm Hg
D)Capillary refill greater than 3 seconds

Question 40

The nurse is monitoring hourly urine output on a patient who has a urinary catheter inserted. The nurse understands that the kidneys can tolerate reduced blood flow for about ________________hour(s) before permanent damage occurs, which can be exhibited by reduced urine output that would need to be reported.

Question 41

A patient who is a full code status is found unresponsive. The nurse immediately begins CPR with the understanding that brain cells die when the brain is deprived of oxygen for more than ________________minute(s).