Chapter 9. Nursing Care of Patients in Shock

22. 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 patients apprehension. d. Apply pressure to the bleeding site.

22. ANS: D The first priority is to control the bleeding with direct pressure. A. B. C. The other options may be considered but are not the first priority. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

33. 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.

33. ANS: D Heat exhaustion or heatstroke can also cause hypovolemic shock by excessive water loss through sweating. A. Excessive dilation of veins and arteries can lead to distributive shock. B. There is no evidence to support that the patient is unable to tolerate oral fluids. C. Parasympathetic stimulation causing blood to pool in the extremities is associated with neurogenic shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

34. 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.

34. ANS: A For the geriatric patient, positions should be changed slowly. Age-related losses of cardiovascular reflexes can result in hypotension. B. C. The oxygen and IV flow rates cannot be changed without a health care providers order. D. Trendelenburg position is not indicated for this health problem. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

35. The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock. What should the nurse do if the patients 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.

35. ANS: D The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Cells in the kidneys die when there is a lack of oxygen and nutrients. If there is widespread damage to the kidneys, complete renal failure is likely. A. The nurse needs to do more than document the findings. B. The urinary catheter does not need to be flushed. C. Clamping the catheter for 30 minutes is not going to improve the patients urine output. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

36. 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 Multiple Response Identify one or more choices that best complete the statement or answer the question.

36. ANS: C If the brain is deprived of circulation for more than 4 minutes, brain cells die from a lack of oxygen and glucose. As a result, prolonged shock can result in brain death. A. B. Brain cells do not begin to die until 4 minutes have passed without oxygen and glucose. D. Brain cells are dying if deprived of oxygen and glucose for 8 minutes. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

12. 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.

12. ANS: B 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

13. 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

13. ANS: D 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

14. 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

14. ANS: B 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

15. 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

15. ANS: C 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

17. 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.

17. ANS: D 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 physicians order. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

2. 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 patients 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 patients vital signs? a. Early shock b. Patient anxiety c. Progressive shock d. Parasympathetic response

2. ANS: A 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 patients change in vital signs is not caused by anxiety, progressive shock, or a parasympathetic response. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

23. A patient who had surgery 3 days ago has a temperature of 98F (36.6C), 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

23. ANS: A During the early, or warm, phase of septic shock, blood pressure, urine output, and neck vein size may be normal, but the skin is warm and flushed. Fever is present in the majority of patients, although some may have a subnormal temperature. D. Septic shock progresses to a second phase with signs and symptoms similar to hypovolemic shock: hypotension; oliguria; tachycardia; tachypnea; flat jugular and peripheral veins; and cold, clammy skin. Body temperature may be normal or subnormal. B. C. There is no reason to suspect that this patient is experiencing neurogenic or cardiogenic shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

24. 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

24. ANS: A Normal blood pressure, tachycardia, and rapid respirations occur in mild shock due to compensatory mechanisms. B. C. D. As shock progresses and compensatory mechanisms begin to fail, vital signs decrease. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

26. 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

26. ANS: B Subcategories of distributive shock include anaphylactic, septic, and neurogenic shock. A. Obstructive shock is caused by a blockage of blood flow in the cardiovascular circuit outside the heart. C. Cardiogenic shock is caused by heart pump failure. D. Hypovolemic shock is caused by a decrease in the circulating blood volume. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

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

27. ANS: B Anaerobic metabolism results in the production of lactic acid as an unwanted by-product. Unless the lactic acid can be circulated to the liver and removed from the bloodstream, the blood will become increasingly acidic. A. Metabolic acidosis will not develop in the presence of aerobic metabolism. C. Decreased anaerobic metabolism will not cause metabolic acidosis to develop. D. The release of cortisol and glucagon ensures the body tissues receive fuel because of the shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

28. 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

28. ANS: A Septic shock can develop from invasive procedures and devices. Indwelling urinary catheters can precipitate the development of septic shock. B. C. D. Cardiogenic, anaphylactic, and hypovolemic shock are not associated with the use of urinary catheters. PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

29. 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

29. ANS: B Symptoms of decompensated shock include slowing heart rate, systolic blood pressure less than 60 mm Hg, decreasing temperature, decreasing respiration rate, and almost no urine output as compensation mechanisms have failed and death is imminent. A. C. D. These manifestations do not indicate that the patient is in mild, moderate, or compensated shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

3. 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

3. ANS: D 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

30. After collecting data, the nurse suspects that a patient is experiencing cardiogenic shock. Which finding supports this nurses suspicion? a. Oliguria b. Tachypnea c. Bronchospasm d. Pulmonary edema

30. ANS: D The presence of pulmonary edema is what differentiates cardiogenic shock from other forms of shock. A. B. C. Oliguria, tachypnea, and bronchospasm are manifestations associated with other forms of shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

31. 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 patients plan of care? a. Hopelessness b. Risk for aspiration c. Excess fluid volume d. Inadequate tissue perfusion

31. ANS: D Shock is defined as inadequate tissue perfusion so the nursing diagnosis of inadequate tissue perfusion is appropriate for the nurse to recommend. A. Shock does not necessarily lead to hopelessness. B. The patient in shock is not necessarily at risk for aspiration. C. Excess fluid volume would be appropriate for the patient experiencing cardiogenic shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

32. 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

32. ANS: C The patient may be having an allergic reaction and requires immediate attention to intervene as anaphylactic shock may occur. A. B. D. There are no abnormalities occurring that require immediate intervention. PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level: Analysis

39. 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

39. ANS: A Tachycardia will not be present as expected with sympathetic nervous system activation. Beta blockers block the response of the sympathetic nervous system, which is activated in shock. B. The sympathetic nervous system is activated in shock so respirations increase. C. Blood pressure drops in shock. D. Prolonged capillary refill is expected in shock due to decreased blood pressure and vasoconstriction from sympathetic nervous system response. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

4. 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.

4. ANS: D 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

40. 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.

40. ANS: A, B, E, F F. As a compensatory mechanism (fight or flight), blood is shunted away from the skin, kidneys, and intestines to supply the major organs. A. Blood glucose levels increase for energy. B. Sodium and water are retained to ensure adequate fluid volume. E. Epinephrine is released from the adrenal medulla to stimulate increased cardiac output. C. D. Vasoconstriction occurs, and the goal is to increase oxygen delivered to the tissues. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

43. 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

43. ANS: E, F Acute respiratory distress syndrome, disseminated intravascular coagulation, and multiple organ dysfunction syndrome are three serious conditions that may follow a prolonged episode of shock. A. B. C. D. Sepsis, malnutrition, diabetes mellitus, and cerebrovascular accident are not considered complications of shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

44. 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.

44. ANS: A, B, C, D, E, F The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

5. A patient with hypovolemic shock is experiencing oliguria due to hemorrhage. Which should the nurse recognize as the most likely cause of the patients oliguria? a. End-stage renal failure b. Secretion of aldosterone c. Inadequate oral fluid intake d. Obstructed urinary catheter

5. ANS: B 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

25. 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.

25. ANS: D Neurogenic shock is a form of distributive shock in which massive vasodilation of the peripheral circulation occurs, causing hypotension. A. B. C. Neurogenic shock is not caused by an allergic reaction, drop in circulating blood volume, or heart failure. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

38. 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

38. ANS: A, B, C, D, F Complete blood count, chest x-ray, blood typing and crossmatch, arterial blood gases, and urinalysis are diagnostic tests done in the assessment of shock. E. EEG would not be done. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

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

46. ANS: C, D Perfusion is first evident in peripheral pulses. An increase in blood pressure occurs because of an improvement in circulating blood volume. A. B. Increasing heart and respiratory rates indicate that the patient is not improving. E. A urine output of less than 30 mL per hour indicates insufficient perfusion of the kidneys caused by the shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

7. 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 patients respiratory rate? a. Electrolyte imbalances b. Inadequate tissue perfusion c. Rapid rate of fluid replacement d. Reaction to the blood transfusion

7. ANS: B 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 patients 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

18. A patient hemorrhaging from an incision has a blood pressure of 70/40 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 Ringers with 50 mL albumin

18. ANS: A 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 patients status and need to replace the lost blood. D. Lactated Ringers might be used to increase fluid volume however albumin will not be used. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

16. 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.

16. ANS: B 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

19. 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

19. ANS: B 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation| Cognitive Level: Application

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

42. ANS: B, C, E Anaphylactic shock symptoms include urticaria, pruritus, wheezing, laryngeal edema, angioedema, and severe bronchospasm. A. Decreased urine rather than increased urination would be seen in a patient in shock. D. Muscle cramps are not associated with anaphylactic shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

45. 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.

45. ANS: A, B, D, E A compromised airway must be treated immediately with the head-tilt/chin-lift method, an oral or nasal airway, or endotracheal intubation. C. Applying 100% oxygen via face mask will not be effective if the patient does not have an airway. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

41. 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

41. ANS: A, B A patient in shock is acutely ill and experiencing anxiety. Keeping the patient informed as able will help reduce anxiety and provide support as treatment plans are shared. C. The patient is acutely ill and most likely not able to learn anything at this time. D. E. Explaining procedures and treatments will not reduce the signs of shock or prevent future episodes of shock. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

8. 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.

8. ANS: C 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

9. After an episode of shock, a patients 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

9. ANS: B 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

1. 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 98.6F (37C). 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 98.6F (37C) d. Blood pressure 130/90 mm Hg

1. ANS: B 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

10. After an episode of shock, a patients 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

10. ANS: D 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

11. 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.

11. ANS: D Shock is defined as inadequate tissue perfusion, in which there is insufficient delivery of oxygen and nutrients to the bodys 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

20. 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

20. ANS: B 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. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

21. A patient with a history of a myocardial infarction has chest pain. The patients 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.

21. ANS: B The charge nurse can notify the physician so orders can be received to aid the critically ill patient. A. The supine position would hinder breathing. D. Increased fluids could overwhelm the heart. C. Urine specific gravity is used to determine fluid volume status and is not needed for this patient. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

37. 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 101F (38.3C) e. Blood pressure 110/90 mm Hg f. Urine output less than 25 mL/hr

37. ANS: A, C, E Oxygen saturation of 94%, pulse of 75 beats/minute, and blood pressure of 110/90 mm Hg all indicate that the patient is improving. F. Urine output should be 30 mL/hr to be normal. D. Normal temperature is 98.6F (37C). B. pH below 7.35 is abnormal and indicates ongoing acidosis related to shock. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

6. 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 patients medical history from family. d. Reorient the patient to person, place, and time.

6. ANS: B 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 patients medical history can be obtained at a later time. D. The patient can be reoriented at a later time. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application