Deck 39: Care of Patients With Shock

Question 1

A client recovering from septic shock is preparing for discharge home.What priority information does the nurse include in the teaching plan for this client?

A) "Clean your toothbrush with laundry bleach daily."
B) "Bathe every other day with antimicrobial soap."
C) "Wash your hands after changing pet litter boxes."
D) "Use an electric razor when you shave your face."

Answer 1

"Clean your toothbrush with laundry bleach daily."

Question 2

The nurse is assessing a client who was admitted for treatment of shock.Which manifestation indicates that the client's shock is caused by sepsis?

A) Hypotension
B) Pale clammy skin
C) Anxiety and confusion
D) Oozing of blood at the IV site

Answer 2

Oozing of blood at the IV site

Question 3

The emergency department nurse is triaging clients.Which client does the nurse assess most carefully for hypovolemic shock?

A) 15-year-old adolescent who plays high school basketball
B) 24-year-old computer specialist who has bulimia
C) 48-year-old truck driver who has a 40-pack-year history of smoking
D) 62-year-old business executive who travels frequently

Answer 3

24-year-old computer specialist who has bulimia

Question 4

A client who has septic shock is admitted to the hospital.What priority intervention does the nurse implement first?

A) Obtain two sets of blood cultures.
B) Administer the prescribed IV vancomycin (Vancocin).
C) Obtain central venous pressure (CVP) measurements.
D) Administer the prescribed IV norepinephrine (Levophed).

Question 5

A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding.Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock?

A) "Are you more thirsty than normal?"
B) "When was the last time you urinated?"
C) "What is your normal heart rate?"
D) "Is your skin usually cool and pale?"

Question 6

The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin)drip.Which manifestation is a desired response to this medication?

A) Decrease in blood pressure
B) Increase in heart rate
C) Increase in cardiac output
D) Decrease in mean arterial pressure

Question 7

The nurse is planning care for a client with late-phase septic shock.All of the following treatments have been prescribed.Which prescription does the nurse question?

A) Enoxaparin (Lovenox) 40 mg subcutaneous twice daily
B) Transfusion of 2 units of fresh frozen plasma
C) Regular insulin intravenous drip per protocol
D) Cefazolin (Ancef) 1 g IV every 6 hours

Question 8

The nurse is administering prescribed sodium nitroprusside (Nipride)intravenously to a client who has shock.Which nursing intervention is a priority when administering this medication?

A) Ask if the client has chest pain every 30 minutes.
B) Assess the client's blood pressure every 15 minutes.
C) Monitor the client's urinary output every hour.
D) Observe the client's extremities every 4 hours.

Question 9

The intensive care nurse is educating the spouse of a client who is being treated for shock.The spouse states,"The doctor said she has shock.What is that?" What is the nurse's best response?

A) "Shock occurs when oxygen to the body's tissues and organs is impaired."
B) "Shock is a serious condition, but it is not a life-threatening emergency."
C) "Shock progresses slowly and can be stopped by the body's normal compensation."
D) "Shock is a condition that affects only specific body organs like the kidneys."

Question 10

The nurse is caring for a client who has had an anaphylactic event.Which priority question does the nurse ask to determine whether the client is experiencing distributive shock?

A) "Is your blood pressure higher than usual?"
B) "Are you having pain in your throat?"
C) "Have you been vomiting?"
D) "Are you usually this swollen?"

Question 11

The nurse is caring for a client in the hyperdynamic phase of septic shock.Which medication does the nurse expect to be prescribed?

A) Heparin sodium
B) Vitamin K
C) Corticosteroids
D) Hetastarch (Hespan)

Question 12

A client was admitted 2 days ago with early stages of septic shock.Today the nurse notes that the client's systolic blood pressure,pulse pressure,and cardiac output are decreasing rapidly.Which intervention does the nurse do first?

A) Insert a Foley catheter to monitor urine output closely.
B) Ask the client's family to come to the hospital because death is near.
C) Initiate the prescribed dobutamine (Dobutrex) intravenous drip.
D) Obtain blood cultures before administering the next dose of antibiotics.

Question 13

A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement.Which fluid does the nurse prepare to administer?

A) Normal saline
B) Ringer's lactate
C) 5% dextrose in water
D) 5% dextrose in 0.45% normal saline

Question 14

The nurse is caring for multiple clients in the emergency department.The client with which condition is at highest risk for distributive shock?

A) Severe head injury from a motor vehicle accident
B) Diabetes insipidus from polycystic kidney disease
C) Ischemic cardiomyopathy from severe coronary artery disease
D) Vomiting of blood from a gastrointestinal ulcer

Question 15

The nurse is assessing a client who has hypovolemic shock.Which laboratory value indicates that the client is at risk for acidosis?

A) Decreased serum creatinine
B) Increased serum lactic acid
C) Increased urine specific gravity
D) Decreased partial pressure of arterial carbon dioxide

Question 16

The nurse is providing community education for clients at risk for dehydration.One client states,"We are not at risk because we live in a hot and dry climate." What is the nurse's best response?

A) "You are still at risk but not as high a risk as those who live in hot and humid climates."
B) "Any type of heat can cause peripheral vasoconstriction, which causes the body to lose water."
C) "In a hot and dry environment, the body can lose an increased amount of water without your knowledge."
D) "Even though you are not at risk, you should drink adequate fluids when you exercise."

Question 17

The nurse is caring for a client who has hypovolemic shock.After administering oxygen,what is the priority intervention for this client?

A) Administer an aminoglycoside.
B) Initiate a dopamine hydrochloride (Intropin) drip.
C) Administer crystalloid fluids.
D) Initiate an intravenous heparin drip.

Question 18

The nurse is assessing a client at risk for shock.The client's systolic blood pressure is 20 mm Hg lower than baseline.Which intervention does the nurse perform first?

A) Increase the IV fluid rate.
B) Administer oxygen.
C) Notify the health care provider.
D) Place the client in high Fowler's position.

Question 19

The nurse is assessing clients in the emergency department.Which client is at highest risk for developing septic shock?

A) 25-year-old man who has irritable bowel syndrome
B) 37-year-old woman who is 20% above ideal body weight
C) 68-year-old woman who is being treated with chemotherapy
D) 82-year-old man taking beta blockers for hypertension

Question 20

The nurse is preparing to administer sodium nitroprusside (Nipride)to a client.Which important action related to the administration of this drug does the nurse implement?

A) Assess the client's respiratory rate.
B) Administer the medication with gravity tubing.
C) Protect the medication from light with an opaque bag.
D) Monitor for hypertensive crisis.

Question 21

The nurse is assessing a client who is in early stages of hypovolemic shock.Which manifestations does the nurse expect?

A) Elevated heart rate
B) Elevated diastolic blood pressure
C) Decreased body temperature
D) Elevated respiratory rate
E) Decreased pulse rate

Question 22

A client has septic shock.Which hemodynamic parameters does the nurse correlate with this type of shock?

A) Decreased cardiac output
B) Increased cardiac output
C) Increased blood glucose
D) Decreased blood glucose
E) Increased serum lactate
F) Decreased serum lactate

Question 23

The nurse is providing health education to a client on immunosuppressant therapy.Which instructions does the nurse include in this client's teaching?

A) "Wear a facemask at all times."
B) "Take your temperature once a day."
C) "Drink only bottled water."
D) "Avoid any contact with pets."
E) "Wash dishes with hot sudsy water."
F) "Rinse your toothbrush in liquid laundry bleach."

Question 24

The nurse is assessing a client who has septic shock.The following assessment data were collected:
The nurse correlates these findings with which stage of shock?

A) Early
B) Compensatory
C) Intermediate
D) Refractory

Question 25

A client who has a local infection of the right forearm is being discharged.The nurse teaches the client to seek immediate medical attention if which complication occurs?

A) Dizziness on changing position
B) Increased urine output
C) Warmth and redness at site
D) Low-grade temperature

Question 26

The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress.Which nursing intervention is most appropriate during this stage of sepsis?

A) Check blood glucose levels every 4 hours.
B) Monitor intake and urinary output twice each shift.
C) Decrease ventilator rate and tidal volume.
D) Administer prescribed low-dose corticosteroids.

Question 27

The nurse is planning discharge education for a client who had an exploratory laparotomy.Which nursing statement is appropriate when teaching the client to monitor for early signs of shock?

A) "Monitor how much urine you void and report a decrease in the amount."
B) "Take your temperature daily and report any below-normal body temperatures."
C) "Assess your radial pulse every day and report an irregular rhythm."
D) "Monitor your bowel movements and report ongoing constipation or diarrhea."