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?

Accepted Answer

Collecting data is the first step in critically thinking about a situation.In this case,the urine output is lower than normal,which could be due to several reasons.The initial action of the nurse should be to inspect the urinary catheter system for proper functioning.If the catheter system is inhibiting urine output,then that issue must be addressed to correct the situation.Other interventions will not help if the system is the cause.B.Catheter irrigation is invasive and breaks the sterile system.A.Oral fluids will not help if the system is kinked; also the patient is confused and so may not be able to take oral fluids safely,and an IV is infusing to hydrate the patient.C.An order is needed to increase the IV rate.

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?

Accepted Answer

An isotonic solution such as 0.9% normal saline will be given immediately to restore fluid volume.B.B.Blood products will be considered based on the patient's status and need to replace the lost blood.D.Lactated Ringer's might be used to increase fluid volume however albumin will not be used.

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?

Accepted Answer

Stimulation of the renin-angiotensin-aldosterone system from decreased cardiac output causes vasoconstriction and retention of sodium and water to decrease further fluid loss,resulting in oliguria.A.There is no evidence to support that the patient is in end-stage renal failure.C.Since the patient is in hypovolemic shock,it is unlikely that oral fluids are being provided.D.There is not enough information to support that a urinary catheter is kinked in this patient.

Question 4

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

Accepted Answer

Respiratory distress is most life threatening and so must be addressed first.It is easier to breathe in an upright position so elevating the head of the bed should be done.A.The prone position will not facilitate oxygenation.C.D.The Trendelenburg or elevating the foot of the bed will not aid with oxygenation.

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?

Accepted Answer

When blood pressure falls,the body activates the sympathetic nervous system to increase cardiac output to deliver adequate oxygen to the tissues by causing the heart to beat faster and stronger.Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool,clammy skin with pallor.A.An electrolyte imbalance will not affect the patient's respiratory rate.C.The fluids should provide the body with needed volume and reduce the rapid respiratory rate.D.A blood transfusion reaction would have manifestations other than a rapid respiratory rate.

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?

Accepted Answer

The patient data indicates possible cardiogenic shock.This means that any fluid given may overwhelm the heart,which could lead to death.The nurse should question IV orders for a cardiogenic shock patient.A.C.D.An ECG,ABGs,or oxygen would be appropriate orders.

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?

Accepted Answer

Decreased afterload occurs from vasodilation that occurs from morphine.Shock is characterized by hypotension,so any drug such as morphine that decreases blood pressure should be avoided or used cautiously.A.C.D.Benadryl,Solu-Medrol,and Dopamine are all medications used to treat shock.

Question 8

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

Accepted Answer

Shock is defined as inadequate tissue perfusion,in which there is insufficient delivery of oxygen and nutrients to the body's tissues and inadequate removal of waste products from these tissues.A.Shock can occur from a massive blood loss but the mechanism is more involved.B.Shock can cause profound circulatory collapse however the mechanism also includes an inadequate amount of oxygen reaching body tissues.C.The term shock is not being used because an overwhelming emotion.

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?

Accepted Answer

When blood pressure falls,the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger.Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool,clammy skin with pallor.A.C.D.These findings are all within normal limits and do not necessarily indicate manifestations of early shock.

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?

Accepted Answer

When cells are deprived of oxygen,they shift to anaerobic metabolism,resulting in the production of lactic acid.Unless the lactic acid is removed from the bloodstream,the blood will become increasingly acidic,resulting in metabolic acidosis.C.Inadequate ventilation leads to respiratory acidosis as CO₂ levels rise.A.Hyperventilation leads to respiratory alkalosis as CO₂ levels decrease.B.Aerobic metabolism is normal.

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?

Accepted Answer

The first priority is to control the bleeding with direct pressure.Elevating the legs will also help.A.The charge should be notified while the bleeding is being controlled by calling for assistance.B.C.Oxygen and IV fluids may be needed but require a physician's order.

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?

Accepted Answer

The priority is to assess the patient in shock quickly,starting with the Cs: airway,breathing,circulation,and disability.A.Covering with blankets can occur after the initial rapid assessment is completed.C.The patient's medical history can be obtained at a later time.D.The patient can be reoriented at a later 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?

Accepted Answer

Because blood is shunted away from the kidneys early in shock to save fluid and provide oxygen to vital organs,the kidneys commonly are injured first.The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage.Urine output should be monitored for reduction to detect injury.D.Pupils that are equally reactive to light are normal.B.Bowel sounds typically remain hypoactive after surgery.A.Acidosis is expected with shock,and a pH within normal limits is normal.

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?

Accepted Answer

Dopamine strengthens myocardial contraction,increases systolic blood pressure,and increases cardiac output.A.Dopamine is not an analgesic.B.Dopamine increases the heart rate.D.Dopamine does not affect respiratory rate.

Question 15

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

Accepted Answer

Patients may have symptoms including wheezing,laryngeal edema,angioedema,and severe bronchospasm,which make it essential for the nurse to ensure a patent airway first.A.C.D.The other actions may be done but are a lower priority than a patent airway.

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?

Accepted Answer

The liver may be injured both by ischemia and by toxins created by the shock state as blood is circulated through it for cleansing.Signs and symptoms of liver injury include decreased production of plasma proteins; abnormal clotting,because clotting factor production by the liver is impaired; and elevated serum levels of ammonia,bilirubin,and liver enzymes.A.C.D.Changes in ammonia,bilirubin,plasma proteins,and clotting factors are not associated with damage to the heart,kidneys,or 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?

Accepted Answer

Signs and symptoms of liver injury include abnormal clotting because clotting factor production by the liver is impaired,so the nurse monitors for coagulation disorders such as disseminated intravascular coagulation.A.B.C.Alterations in clotting factors will not predispose the patient to develop a brain attack,multisystem organ failure,or adult respiratory distress syndrome.

Question 18

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

Accepted Answer

After ensuring a patent airway,the priority treatment interventions are providing cardiovascular support to maintain systolic blood pressure at least at 90 mm Hg.IV access is critical to provide fluids first and then antibiotics.D.Reassuring the patient is not the first priority.A.C.Septic shock is related to infection,so obtaining a temperature and determining medication allergies,as antibiotics will be given,will take place after the IV is started.

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?

Accepted Answer

Pain,anxiety,and cold all increase body tissue demands for blood and oxygen.This places an increased workload on the heart.Maintaining normal body temperature and reducing pain and anxiety will reduce oxygen demand.A.B.C.Maintaining normal body temperature and reducing pain and anxiety will not impact fluid balance or increase 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?

Accepted Answer

When blood pressure falls,the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger.Compensatory responses produce the classic signs and symptoms of early shock: tachycardia; tachypnea; restlessness; anxiety; and cool,clammy skin with pallor.B.C.D.The patient's change in vital signs is not caused by anxiety,progressive shock,or a parasympathetic response.

Quiz 9: Nursing Care of Patients in Shock

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?