Saunders Shock Questions

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse plans for which intervention as the priority for this client? 1. Administration of dopamine 2. Administration of whole blood 3. Administration of intravenous fluids 4. Administration of packed red blood cells

1. Administration of dopamine

Which finding indicates that tissue perfusion has been improved in a client with septic shock? 1. The client's capillary refill is less than 3 seconds. 2. The client's blood glucose has decreased to 120 mg/dL. 3. The client tolerated a rapid infusion of isotonic intravenous fluids. 4. The client's pulse oximetry is maintained at 94% on 4 liters per minute of oxygen via nasal cannula.

1. The client's capillary refill is less than 3 seconds

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased, and the blood pressure is 92/68 mm Hg. The nurse suspects which stage of shock based on this data? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2. Stage 2

A client who had a myocardial infarction is at risk for cardiogenic shock. The nurse plans care knowing that the primary cause of cardiogenic shock results from which process? 1. A pump failure and reduction in cardiac output 2. A physical obstruction that decreases filling or outflow of blood 3. Dilated vasculature decreasing the movement of blood to the body 4. Loss of vasoconstrictor tone, leading to pooling of blood in vessels

1. A pump failure and reduction in cardiac output

The nurse is monitoring the client after cardiac surgery. The nurse notes the following signs and symptoms: decreased urinary output, decreased bowel sounds, capillary refill >4 seconds, and changes in mental status. What would the nurse do next? 1. Continue to monitor; these may be signs of potential shock. 2. Collect an arterial blood gas to check to see whether the client is compensating. 3. Place the client on oxygen; these are signs of increased oxygen requirement. 4. Contact the primary health care provider (PHCP); these may be signs of potential shock.

4. Contact the primary health care provider (PHCP); these may be signs of potential shock.

A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial pressure (MAP) of 60 mm Hg. Which prescribed intervention would the nurse implement first? 1. Increase the rate of O2 flow. 2. Obtain arterial blood gas results. 3. Insert an indwelling urinary catheter. 4. Increase the rate of intravenous (IV) fluids.

4. Increase the rate of intravenous (IV) fluids.

Due to an extreme staff shortage, the nurse has been sent to the intensive care unit to assist registered nurses in the care of clients. The nurse understands that which factor is most important to consider when treating a client with cardiogenic shock? 1. Use of diuretics to decrease circulating volume 2. Use of whole blood to easily restore fluid volume 3. Use of intravenous and oral fluids to restore circulating volume 4. Restriction of volume expanders because of secondary pulmonary edema

4. Restriction of volume expanders because of secondary pulmonary edema

The nurse is caring for a client with cardiogenic shock. After reviewing the medication administration record, the nurse determines a need for follow-up when noticing which entry in the record? 1. Digoxin 0.5 mg/day orally 2. Morphine sulfate 2 mg intravenous (IV) PRN for chest pain 3. Verapamil 10 mg IV; may repeat every 15 minutes 4. Dopamine IV 1 mcg/kg/min to maintain systolic BP >100 mm Hg

4. Verapamil 10 mg IV; may repeat every 15 minutes

A new graduate nurse is taking a critical care course focusing on cardiogenic shock. Which statement made by the graduate nurse indicates that the teaching was effective? 1. Cardiogenic shock is caused by diuretics. 2. Cardiac tissue death can lead to cardiogenic shock. 3. Cardiac arrest is the most common cause for cardiogenic shock. 4. Each valve within the heart must be faulty to decrease cardiac output.

2. Cardiac tissue death can lead to cardiogenic shock.

The charge nurse understands that there is a need for further teaching when the nurse caring for a client with septic shock states which of the following? 1. "Frequent assessments of mental status may be necessary." 2. "It will be important to watch the trend of the client's lab values." 3. "Blood transfusions may be needed to help with the client's coagulopathy." 4. "Administering antibiotics is the best way to correct and treat septic shock."

4. "Administering antibiotics is the best way to correct and treat septic shock." Rationale - Antibiotics are an important piece of the treatment and management of shock, but the treatment and management encompass many different interventions and methods, not just administering antibiotics.

What primary characteristic of cardiogenic shock helps determine what nursing interventions are performed? 1. Blood pools in the heart, so care is focused on diuresing. 2. Urinary output is low, so care is focused on increasing circulating volume. 3. Hypotension is severe, so care is focused on blood pressure monitoring. 4. Cardiac output is compromised, so care is focused on restoring tissue perfusion.

4. Cardiac output is compromised, so care is focused on restoring tissue perfusion.

The nurse caring for a client suspected of being in hypovolemic shock is trying to anticipate treatment and management interventions. What plan is most appropriate for this client? Select all that apply. 1. Oxygen administration 2. Mental status checks every 15 minutes 3. Further assessment to confirm the type of shock 4. High-dose diuretics to minimize fluid accumulation 5. Laboratory blood draws every 30 minutes to trend abnormal values

1. Oxygen administration 2. Mental status checks every 15 minutes 3. Further assessment to confirm the type of shock Rationale - Every 30 minutes isn't necessary, can't use diuretics because there's nothing there to diuresis.

The nurse plans care understanding that which is the primary reason clients experience vasodilation in septic shock? 1. There is a release of endotoxins from bacteria. 2. There is heart failure with diminished cardiac output. 3. There is blood or fluid loss, and the body compensates by dilating the blood vessels. 4. There is an obstruction of blood flow, and the body compensates by dilating the blood vessels.

1. There is a release of endotoxins from bacteria.