Deck 9: Nursing Care of Patients in Shock

Question 1

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.Intravenous (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.

Answer 1

Check urinary catheter for kinking.

Question 2

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

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

Answer 2

0.9 % normal saline

Question 3

A patient with hypovolemic shock is experiencing oliguria due to hemorrhage.Which should the nurse recognize as the most likely cause of the patient's oliguria?

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

Answer 3

Secretion of aldosterone

Question 4

A patient is experiencing respiratory distress and mild shock.In which position should the nurse place the patient?

A) Prone
B) Head elevated
C) Trendelenburg position
D) Flat with elevated foot of bed

Question 5

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 6

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% NS over 30 minutes
C) Oxygen 2 L/min via nasal cannula
D) Arterial blood gases (ABGs) STAT and repeat in 1 hour

Question 7

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 8

The family of a patient in shock asks the nurse to explain the condition.How should the nurse respond to this family?

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

Question 9

A patient with gastrointestinal bleeding is awake,alert,and oriented and has vital sign measurements of: 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 10

A patient involved in a motor vehicle accident has pale mucous membranes,diaphoresis,confusion,blood pressure 88/48 mm Hg,irregular heart rhythm,and metabolic acidosis.Which finding should the nurse recognize as the likely cause of acidosis?

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

Question 11

A patient recovering from vascular leg surgery is found standing in a large pool of blood flowing from the surgical site.After assisted into bed,the patient is pale with a palpable pulse.What action should the nurse take?

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

Question 12

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

Question 13

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 upon immediately?

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

Question 14

A patient is receiving a dopamine infusion for shock.What should the nurse expect to assess in the patient because of this medication?

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

Question 15

A patient is demonstrating signs of anaphylactic shock.What action should the nurse take first?

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

Question 16

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.Which organ should the nurse recognize as being damaged from the shock?

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

Question 17

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

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

Question 18

A patient is admitted with suspected septic shock.Which action should the nurse take first?

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

Question 19

The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a patient who is experiencing shock.What is the purpose of the nurse performing these actions?

A) Increases fluid volume
B) Decreases fluid volume
C) Increases oxygen demand
D) Decreases oxygen demand

Question 20

A patient with gastrointestinal bleeding has hemoglobin of 8.5 g/dL.While receiving care the patient becomes anxious and irritable and bright red drainage appears through the nasogastric tube.The patient's vital sign measurements are pulse 130 beats/minute,blood pressure 105/55 mm Hg,and respirations 28/minute.What should the nurse recognize as causing the changes in the patient's vital signs?

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

Question 21

A patient in shock has a falling blood pressure.What should the nurse realize occurs as the sympathetic nervous system responds to falling blood pressure? (Select all that apply.)

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

Question 22

A patient is admitted for care because of heat stroke.Why should the nurse include interventions to prevent the onset of shock?

A) The heat causes excessive dilation of veins and arteries.
B) Inability to tolerate oral fluids could lead to more water lost.
C) Parasympathetic stimulation causes blood to pool in the extremities.
D) Excessive water lost through sweating can lead to hypovolemic shock.

Question 23

The spouse of a patient in neurogenic shock asks what is happening to the patient.How should the nurse response to the spouse?

A) "This is because of an allergic reaction."
B) "There is a drop in circulating blood volume."
C) "The heart has failed to pump blood throughout the body."
D) "The blood vessels have dilated and lowered the blood pressure."

Question 24

The nurse is assisting in the planning of care for a patient in shock.Which nursing diagnoses should the nurse recommend be included in the patient's plan of care?

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

Question 25

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) Arterial blood gas
D) Complete blood count
E) Electroencephalogram (EEG)
F) Blood type and crossmatch

Question 26

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 should indicate to the nurse that the patient is in which stage of shock?

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

Question 27

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 28

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?

A) 1
B) 2
C) 4
D) 8

Question 29

The nurse is monitoring a patient being for septic shock.Which findings indicate that the patient is improving? (Select all that apply.)

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

Question 30

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 31

Patients are being treated in the intensive care unit for anaphylactic,septic,and neurogenic shock.For which type of shock should the nurse plan to provide care?

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

Question 32

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 type of shock should the nurse suspect is occurring in this patient?

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

Question 33

The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock.What should the nurse do if the patient's urine output drops to 15 mL for one hour of monitoring?

A) Document the finding.
B) Flush the urinary catheter
C) Clamp the catheter for 30 minutes.
D) Immediately report the drop in urine output.

Question 34

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% normal saline wide open.

Question 35

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 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 36

After collecting data,the nurse suspects that a patient is experiencing cardiogenic shock.Which finding supports this nurse's suspicion?

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

Question 37

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

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

Question 38

A patient who is taking atenolol (Tenormin)is experiencing shock.Which symptom of shock should the nurse expected to be absent in this patient?

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 39

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

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

Question 40

The nurse discovers that a patient recovering from surgery is hemorrhaging from the incisional site.What action should the nurse take?

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

Question 41

The nurse is monitoring a patient who has been in a shock state for several days.For which serious complications should the nurse observe in the patient and then report? (Select all that apply.)

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

Question 42

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 43

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.

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 44

The nurse determines that a patient with severely bleeding wounds does not have an adequate airway.What should the nurse do to help this patient? (Select all that apply.)

A) Insert an oral airway.
B) Insert a nasal airway.
C) Apply 100% oxygen via face mask.
D) Prepare for endotracheal intubation.
E) Attempt the head tilt/chin lift method.

Question 45

The nurse explains procedures and treatments while caring for a patient in shock.Why should the nurse provide these explanations to the patient? (Select all that apply.)

A) Provide support
B) Decrease anxiety
C) Enhance learning
D) Reduce the signs of shock
E) Prevent future shock episodes

Question 46

The nurse determines that a patient with hypovolemic shock is improving.What did the nurse observe to come to this conclusion? (Select all that apply.)

A) Heart rate increasing
B) Respiratory rate increasing
C) Present of peripheral pulses
D) Systolic blood pressure increasing
E) Urine output 20 mL over the last hour