Week 6: Shock states Quiz

Which client is at highest risk of developing obstructive shock?

A client with COPD that is intubated, with high levels of positive pressure ventilation

A client presents with cardiogenic shock and asks the nurse, "What is happening to me?" How would the nurse describe cardiogenic shock?

A failure of the circulatory pump

Which change in the client's lab results indicates the client is experiencing septic shock?

An increased serum lactate level

During a blood transfusion, a client calls the nurse and says, "It's really hard to breathe." Upon assessment the nurse notes an increased heart rate, low blood pressure, and a rash. Which type of shock would the nurse suspect the client is experiencing?

Anaphylactic shock

Which is an expected finding in a client with hypovolemic shock?

Cool, clammy skin

A client is being treated for hypovolemic shock. What diagnostic indicates that the client's shock state is resolving?

Decrease in the serum lactate level

Which prescribed action would the nurse perform first when caring for a client who presents to the ED with an elevated temperature, elevated white blood cell count, evidence of an infected foot ulcer, with a blood pressure of 110/76?

Draw peripheral blood cultures from two different sites.

An elderly client is admitted to the ED with complaints of fatigue, burning with urination, and intermittent confusion. The client's admitting weight is 75 kg. The vital signs are temperature 35.3°C, pulse 120 beats per minute, respirations 24 per minute, and blood pressure 86/54 mm Hg. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours was 20 mL via a Foley catheter. Which intervention would the nurse recommend to the primary health care provider?

Facilitate a transfer to an intensive care unit

A client is admitted after suffering a transection of the spinal cord at C7-C8. Which clinical manifestation is expected immediately after his injury?

Flaccid paralysis

During a paracentesis, 2500 mL of fluid is removed. Which assessment finding by the nurse requires additional assessment and interventions?

Heart rate increases from 70 to 130 beats per minute

A client is admitted to the emergency department after a motor cycle crash with extensive abdominal bruising, a blood pressure of 62/39 mm Hg, and a heart rate of 125 beats/minute. What type of shock is the client most likely undergoing?

Hemorrhagic shock

Which finding will cause the nurse to suspect cardiac tamponade in a client who has had cardiac surgery?

Jugular vein distention (JVD)

A client is admitted to the intensive care unit in the progressive stage of septic shock. What change in the client's acid-base balance would be most likely?

Metabolic acidosis

What is the immediate intervention for a client with a suspected tension pneumothorax who has a blood pressure of 54/29 and tracheal deviation?

Needle decompression

Which shock state would the nurse suspect in a client with C7 transection, BP of 70/30 mm Hg, pulse of 45 beats per minute, and respiratory rate of 26 breaths per minute?

Neurogenic shock

Which nursing intervention would best prevent septic shock in the hospitalized client?

Perform hand hygiene upon entering and exiting the client's room and before all procedures.

A client is admitted to the progressive floor after a small bowel resection. Which finding would the nurse identify as an early sign of shock?

Restlessness

A client is admitted with a diagnosis of a venous thromboembolism event (VTE) in both lower extremities. The client calls the nurse into the room complaining of a sudden onset of shortness of breath. The client's blood pressure is 75/65, HR 135 beats per minute, and respiratory rate is 34. What condition does the nurse suspect occurred?

Saddle pulmonary embolism

Assessment findings for a client with a crush injury to the chest include obvious left-sided paradoxical motion of the chest and a flail chest. The nurse would monitor the client for which complication?

Tension pneumothorax

Providers place a subclavian central line in a client who is admitted for sepsis and requires vasoactive medications. The client develops shortness of breath and tracheal deviation is noted after the procedure. What condition does the nurse suspect?

Tension pneumothorax