Deck 37: Care of Patients with Shock

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.)

A) Bringing the client warm blankets
B) Giving the client hot tea to drink
C) Massaging the client's painful legs
D) Reorienting the client as needed
E) Sitting with the client for reassurance

Answer 1

Bringing the client warm blankets
Reorienting the client as needed
Sitting with the client for reassurance

Question 2

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

A) Alert and oriented, answering questions
B) Client denial of chest pain or chest pressure
C) IV site without redness or swelling
D) Urine output of 30 mL/hr for 2 hours

Answer 2

Alert and oriented, answering questions

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?

A) Do not get dehydrated in warm weather.
B) Drink fluids on a regular schedule.
C) Seek attention for any lacerations.
D) Take medications as prescribed.

Answer 3

Drink fluids on a regular schedule.

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?

A) Ask if the client needs pain medication.
B) Assess the client's tissue perfusion further.
C) Document the findings in the client's chart.
D) Increase the rate of the client's IV infusion.

Question 5

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

A) Offer to remain with the client for awhile.
B) Prepare to administer antianxiety medication.
C) Raise all four siderails on the client's bed.
D) Tell the client everything possible is being done.

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?

A) "High glucose is common in shock and needs to be treated."
B) "Some of the medications we are giving are to raise blood sugar."
C) "The IV solution has lots of glucose, which raises blood sugar."
D) "The stress of this illness has made your spouse a diabetic."

Question 7

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

A) Apply personal protective equipment.
B) Notify local law enforcement officials.
C) Obtain "universal" donor blood.
D) 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.)

A) Assessing and identifying clients at risk
B) Monitoring the daily white blood cell count
C) Performing proper hand hygiene
D) Removing invasive lines as soon as possible
E) Using aseptic technique during procedures

Question 9

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

A) Client with a blood pressure change of 128/74 to 110/88 mm Hg
B) Client with oxygen saturation unchanged at 94%
C) Client with a pulse change of 100 to 88 beats/min
D) Client with urine output of 40 mL/hr for the last 2 hours

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.)

A) Anaerobic metabolism
B) Hyperglycemia
C) Hypotension
D) Impaired renal perfusion
E) Increased perfusion

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?

A) Assessing the IV site before giving the drug
B) Obtaining a programmable ("smart") IV pump
C) Removing the IV bag from the brown plastic cover
D) Taking and recording a baseline set of vital signs

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?

A) Document the findings in the client's chart.
B) Give the client warmed blankets for comfort.
C) Notify the health care provider immediately.
D) Prepare to administer insulin per sliding scale.

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?

A) Apply direct pressure to the bleeding.
B) Ensure the client has a patent airway.
C) Obtain consent for emergency surgery.
D) Start two large-bore IV catheters.

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?

A) "All my friends and neighbors are planning a party for me."
B) "I hope I can get my water turned back on when I get home."
C) "I am going to have my daughter scoop the cat litter box."
D) "My grandkids are so excited to have me coming home!"

Question 15

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

A) Blood pressure of 98/68 mm Hg
B) Pedal pulses 1+/4+ bilaterally
C) Report of chest heaviness
D) Urine output of 32 mL/hr

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)?

A) It causes vasoconstriction and increased MAP.
B) Lower blood volume lowers MAP.
C) There is no direct correlation to MAP.
D) It raises cardiac output and MAP.

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.)

A) Administer antibiotics.
B) Draw serum lactate levels.
C) Infuse vasopressors.
D) Measure central venous pressure.
E) Obtain blood cultures.

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?

A) Creatinine: 0.9 mg/dL
B) Lactate: 6 mmol/L
C) Sodium: 150 mEq/L
D) White blood cell count: 11,000/mm³

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.)

A) Altered mobility/immobility
B) Decreased thirst response
C) Diminished immune response
D) Malnutrition
E) Overhydration

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?

A) Assess the client for pain or discomfort.
B) Measure urine output from the catheter.
C) Reposition the client to the unaffected side.
D) Stay with the client and reassure him or her.

Question 21

A client with severe sepsis has a serum lactate level of 6.2 mmol/L.The client weighs 250 pounds.To infuse the amount of fluid this client requires in 24 hours,at what rate does the nurse set the IV pump? (Record your answer using a whole number.)____ mL/hr