Shock Questions

A client with septic shock is to receive dopamine at 18 mcg/kg/min. The client's weight is 154 pounds. How many mcg/min does the nurse administer?

1260 mcg/min

SHOCK A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? a. Temperature b. Pulse c. Respiration d. Blood pressure

a A postoperative client's temperature may differentiate pulmonary embolism from early sepsis when the client complains of feeling light-headed and anxious. A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia(pulse), tachypnea(respiration), and hypotension (blood pressure).

A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95°F (35°C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? a. Broad-spectrum antibiotics b. Blood transfusion c. Cooling baths d. NPO status

a From the sepsis resuscitation bundle the nurse initiates broad-spectrum antibiotics within 1 hour of establishing diagnosis. A blood transfusion is indicated for low red blood cell count or low hemoglobin and hematocrit. Transfusion is not part of the sepsis resuscitation bundle. Cooling baths neither are indicated because the client is hypothermic nor are this part of the sepsis resuscitation bundle. NPO status neither is indicated for this client nor is it part of the sepsis resuscitation bundle.

What occurs in septic shock? a. Massive vasodilation b. Increased respiratory rate c. Decreased capillary permeability d. Increased systemic vascular resistance

a RAT: In septic shock, an infection triggers an inflammatory response, which results in massive vasodilation and increased capillary permeability. Respirations are not affected. Capillary permeability is increased. Vasodilation results in decreased systemic vascular resistance.

The nurse is assessing an infant brought to the clinic with diarrhea. He is lethargic and has dry mucous membranes. What would the nurse recognize as an early sign of dehydration? a. Tachycardia b. Bulging, tense fontanel c. Decreased blood pressure d. Capillary refill of less than 3 seconds

a RAT: Tachycardia is the earliest manifestation of dehydration. Fever and infection can also result in tachycardia, so these should be included in the assessment data. A bulging fontanel may be indicative of increased intracranial pressure, not dehydration. Decreased blood pressure is a late sign of dehydration. Capillary refill is slowed and more than 3 seconds in dehydration.

SHOCK The client with which problem is at highest risk for hypovolemic shock? a. Esophageal varices b. Kidney failure c. Arthritis and daily acetaminophen use d. Kidney stone

a The client with esophageal varices is at highest risk for hypovolemic shock. Esophageal varices are caused by portal hypertension where the portal vessels are under high pressure. With this high pressure, the portal vessels are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock.As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Arthritis and daily acetaminophen use do not cause GI bleeding and hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen may predispose the client to gastrointestinal (GI) bleeding and hypovolemia. Although a kidney stone may cause hematuria, massive blood loss or hypovolemia generally does not occur.

SHOCK The unlicensed assistive personnel (UAP) is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do? a. Compare these vital signs with the last several readings. b. Request that the surgeon see the client. c. Increase the rate of intravenous fluids. d. Reassess vital signs using different equipment.

a The supervising nurse will take the vital sign trends into consideration. A BP of 90/60 mm Hg may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment must be used when vital signs are taken postoperatively.

SHOCK A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. a. Ask family members to stay with the client. b. Call the health care provider. c. Increase IV and oxygen rates. d. Remain with the client. e. Reassure the client that everything is being done for him or her.

a, c, d To support the psychosocial integrity of a client in early shock, the nurse would have a familiar person nearby to comfort the client. The nurse would also remain with the client and offer genuine support to reassure the client that everything is being done for her.The health care provider would be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.

Which questions are most important for the nurse to first ask a client who comes to the emergency department with signs of severe angioedema? (Select all that apply.) a. "Are you able to swallow?" b. "When did you last eat or drink?" c. "Do you have an allergy to cortisone?" d. "What drugs do you take on a daily basis"? e. "Is there any possibility that you may be pregnant?" f. "Do any members of your family also have allergies?"

a, d RAT: The client has severe angioedema that can progress rapidly to laryngeal edema and loss of the airway. The very first question should be to assess symptom severity. Asking whether the client can swallow provides an indication of severity. If the client can still swallow, an immediate intubation or tracheotomy is not needed. Asking what drugs he or she takes can help establish the diagnosis and the cause. It is not necessary to know when the last food or drink was taken. Also, regardless of whether the client is pregnant, interventions for angioedema must be started. It is not helpful during this emergency to know whether other family members also have allergies. This information can be obtained at a later time or from family members. Cortisone is used to treat allergies and does not cause them.

Which clients are at immediate risk for hypovolemic shock? Select all that apply. a. Unrestrained client in a motor vehicle collision (MVC) b. Construction worker c. Athlete d. Surgical intensive care unit (SICU) client e. 85-year-old with gastrointestinal (GI) virus

a, d, e Clients who are immediate risk for hypovolemic shock include: the unrestrained client in a (MVC), the SICU client, and the 85-year-old client with GI virus. The client who is unrestrained in a MVC is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock, especially if a gastrointestinal virus is present that results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock. They may, however, be at risk for dehydration.

SHOCK A client thought to be at risk for distributive shock is given a drug that constricts blood vessels. What effect does the nurse expect the drug to have on the client's mean arterial pressure (MAP)? a. Increased MAP without a change in vascular volume. b. Increased MAP by increasing vascular volume. c. Decreased MAP from widespread capillary leak. d. Decreased MAP by decreasing vascular volume.

a. RAT: Distributive shock occurs when blood volume is diverted from the vascular volume into other spaces but without being lost from the body. Drugs that constrict blood vessels, especially arterioles, can keep the remaining vascular volume in place and reduce the size of the capillary bed. These responses increase mean arterial pressure but do not expand the vascular volume.

SHOCK A client who is in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which ones does the nurse attribute to ongoing compensatory mechanisms? (Select all that apply.) a. Increasing pallor b. Increasing thirst c. Increasing confusion d. Increasing heart rate e. Increasing respiratory rate f. Decreasing systolic blood pressure g. Decreasing blood pH h. Decreasing urine output

a., b. d. e. h. RAT: Compensatory mechanisms attempt to maintain perfusion and gas exchange to vital organs. Thus these mechanisms shunt blood away from less vital organs and try to prevent further volume losses. The increasing pallor occurs because blood is shunted away from skin and mucous membranes to the heart, brain, liver, and lungs. Increasing thirst and decreasing urine output help to increase blood volume by stimulating the patient to drink and by preventing fluid loss through the urine. Increasing heart rate and respiratory rate work to maintain gas exchange to those selected organs that continue to be perfused. Increasing confusion indicates the compensatory mechanisms are failing and that the brain is not being adequately perfused. Decreasing systolic blood pressure also is an indication of worsening shock. Decreasing blood pH is not a compensatory action; it is an indication of inadequate gas exchange.

SHOCK Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? a. Client receiving a blood transfusion b. Client with severe ascites c. Client with myocardial infarction d. Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

b A client with severe ascites best demonstrates the problem with the highest risk for hypovolemic shock. Fluid shifts from vascular to intraabdominal may cause decreased circulating blood volume and poor tissue perfusion. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle, but no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

SHOCK Which laboratory result is seen in late sepsis? a. Decreased serum lactate b. Decreased segmented neutrophil count c. Increased numbers of monocytes d. Increased platelet count

b A decreased segmented neutrophil count is indicative of late sepsis. The segmented neutrophils (segs) may no longer be elevated because prolonged sepsis may have exceeded the bone marrow's ability to keep producing and releasing new mature neutrophils. Serum lactate is increased, not decreased, in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis. Late in sepsis, platelets may decrease due to consumptive coagulopathy.

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? a. Hourly urine output 10 to 12 mL/hr b. Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg c. Blood glucose 245 mg/dL (13.6 mmol/L) d. Serum creatinine 3.6 mg/dL (318 mcmol/L)

b A positive outcome of a Dopamine infusion started on a client with septic shock is a blood pressure of 90/60 mm Hg and a mean arterial pressure of 70 mm Hg. Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and are a negative consequence of shock, not a positive response. Although a blood glucose of 245 mg/dL (13.6 mmol/L) is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.

SHOCK Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? a. Localized erythema and edema b. Low-grade fever and mild hypotension c. Low oxygen saturation rate and decreased cognition d. Reduced urinary output and increased respiratory rate

b Low-grade fever and mild hypotension in a postoperative client indicate very early sepsis. With treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate severe sepsis. Reduced urinary output and increased respiratory rate indicate active (not early) sepsis.

A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effect? a. Bradycardia b. Headache c. Infection d. Metabolic alkalosis

b RAT: A client complaint of a headache is an adverse effect of norepinephrine (Levophed). This drug is a vasopressor and can cause headache. Norepinephrine does not suppress the immune system. Tachycardia, not bradycardia, and metabolic acidosis, not alkalosis, are adverse effects of norepinephrine.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? a. Check for fecal impaction. b. Help the client sit up. c. Insert a straight catheter. d. Loosen the client's clothing.

b RAT: The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

SHOCK How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? a. PaCO2 58 mm Hg b. Lactate 81 mg/dL (9.0 mmol/L) c. Partial thromboplastin time 64 seconds d. Potassium 2.8 mEq/L (2.8 mmol/L)

b The client with septic shock and a lactate level of 81 mg/dL (0.9 mmoL/L) indicates that severe tissue hypoxia is present. Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid. Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis, but this value is decreased and is not consistent with septic shock.

SHOCK A postoperative client is admitted to the intensive care unit (ICU) with hypovolemic shock. Which nursing action does the nurse delegate to an experienced unlicensed assistive personnel (UAP)? a. Obtain vital signs every 15 minutes. b. Measure hourly urine output. c. Check oxygen saturation. d. Assess level of alertness.

b The nurse delegates to an experienced ICU UAP the measurement of hourly urine output on a client with hypovolemic shock. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment. The nurse will evaluate the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

SHOCK The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? a. Administer the antibiotic immediately. b. Ensure that blood cultures were drawn. c. Obtain signature for informed consent. d. Take the client's vital signs.

b The nurse's first action when planning to administer an antibiotic to a newly admitted patent in septic shock is to ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours, because timing is essential.

SHOCK Which problem places a client at highest risk for sepsis? a. Pernicious anemia b. Pericarditis c. Post kidney transplant d. Client owns an iguana

c A client with post kidney transplant is the highest risk for sepsis. This client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a greater risk for infection, sepsis, and death.

What typical sign/symptom indicates the early stage of septic shock? a. Pallor and cool skin b. Blood pressure 84/50 mm Hg c. Tachypnea and tachycardia d. Respiratory acidosis

c Early signs/symptoms of systemic inflammatory response syndrome include rapid respiratory rate, leukocytosis, and tachycardia. The early stage of septic shock precedes sepsis. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis and not acidosis occurs early in shock because of an increased respiratory rate.

Depression of the central nervous system (CNS), manifested by lethargy, delirium, stupor, and coma, is observed in what? a. Metabolic acidosis b. Respiratory alkalosis c. Metabolic and respiratory acidosis d. Metabolic and respiratory alkalosis

c RAT: Hydrogen ion imbalances result in CNS involvement. Depression of the CNS, as manifested by lethargy, delirium, diminished mental capacity, stupor, and coma, is found in acidosis that is either metabolic or respiratory in origin. Respiratory acidosis can also manifest these clinical findings. Respiratory and metabolic alkalosis are reflected clinically by CNS excitation and stimulation, nervousness, tingling sensations, and tetany that may progress to seizures.

What is a major complication of total parenteral nutrition in children? a. Anemia b. Asthma c. Liver disease d. Renal impairment

c RAT: Liver disease is the most important gastrointestinal complication of total parenteral nutrition. If present, anemia and asthma are not directly related to the total parenteral nutrition. Renal function is monitored to ensure electrolyte balance, but impairment is not an expected complication.

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? a. Hospital library b. Internet c. National Spinal Cord Injury Association d. Provider's office

c RAT: The best resource for the nurse to provide is the National Spinal Cord Injury Association. The National Spinal Cord Injury Association will inform the client of support groups in the area and will assist in answering questions regarding adjustment in the home setting. The hospital library is not typically consumer-oriented. Most information available in the library is targeted to health care professionals. The Internet is not the best resource simply because of the unlimited volume of information available and its questionable quality. Although the provider's office may have information, the information may not be as comprehensive and current as other options.

A client who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action does the nurse take next? a. Infuse normal saline at 200 mL/hr. b. Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously. c. Discontinue infusing the antibiotic. d. Give diphenhydramine (Benadryl) 100 mg IV.

c RAT: The nurse's first action should be to discontinue the antibiotic. The antibiotic is the most likely cause of the client's apparent anaphylactic reaction. Infusing normal saline and administering epinephrine and diphenhydramine may be indicated, but these are not the nurse's first action.

What are the most common food allergens that need to be considered when educating parents of an infant? a. Fruit, eggs, and rice b. Fruit, vegetables, and wheat c. Eggs, cow's milk, and peanuts d. Cow's milk and green vegetables

c RAT: These are three of the most common food allergens. Ingestion of these products can cause sensitization and, with subsequent exposure, an allergic reaction. Eggs are a common allergen but not fruit or rice. Wheat is a common allergen but not fruit and vegetables. Cow's milk is a common allergen but not green vegetables.

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? a. Dopamine hydrochloride (Inotropin) b. Methylprednisolone (Solu-Medrol) c. Nifedipine (Procardia) d. Ziconotide (Prialt)

c RAT: This client is experiencing autonomic dysreflexia (AD). Nifedipine (Procardia), a calcium channel blocker, can be administered to treat AD and lower blood pressure. If AD is not treated, a hemorrhagic stroke can occur. Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide (Prialt) is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.

SHOCK The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider? a. Admission to rehabilitation hospital for ambulatory retraining b. Collaboration with home care agency for return to home c. Discussion with family and provider regarding palliative care d. Enrollment in a cardiac transplantation program

c When caring for a client in the refractory stage of cardiogenic shock the nurse considers discussing palliative care with the family and provider. In this irreversible phase, therapy is not effective in saving the client's life, even if the cause of shock is corrected and mean arterial pressure temporarily returns to normal. A discussion on palliative care would be considered. Rehabilitation or returning home is unlikely. The client with sustained tissue hypoxia is not a candidate for organ transplantation.

SHOCK With which client should the nurse remain alert for the possibility of sepsis and septic shock? a. 41-year-old man who sustained closed depression fractures on the face when hit with a baseball. b. 53-year-old woman who had an open abdominal hysterectomy 3 days ago to remove several large fibroid tumors. c. 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago. d. 72-year-old man with severe allergies who is undergoing radiation therapy for early-stage prostate cancer.

c. RAT: Anyone taking corticosteroids on a chronic basis has some degree of reduced immunity. This client also had oral surgery to remove teeth. This does constitute a blood exposure to organisms in the mouth because the mouth cannot be sterilized. Also, she is older than 65 years, which also increases her risks. Although the woman with the abdominal surgery also had blood exposure, this was done under sterile surgical conditions and she has no other risk factors. The client with closed depression fractures has no risk factors. The man with prostate cancer, although at some risk because of age, is not placed at further risk by either his early-stage cancer or the radiation therapy.

Which problem places a person at highest risk for septic shock? a. Kidney failure b. Cirrhosis c. Lung cancer d. 40% burn injury

d A client with 40% burn injury is at highest risk for septic shock and possible death. The skin forms the first barrier to prevent entry of organisms into the body. Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client. The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin.

What would the nurse recognize as an early clinical sign of compensated shock in a child? a. Confusion b. Sleepiness c. Hypotension d. Apprehension

d RAT: Early signs are vague and subtle, including apprehension, irritability, normal blood pressure, narrowing pulse pressure, thirst, pallor, and diminished urinary output. Confusion, sleepiness, and hypotension are later signs of shock.

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? a. Getting the client up in a chair b. Keeping the client in the Trendelenburg position c. Lifting the client in unison with other health care personnel d. Log rolling the client

d RAT: Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment. The client who has undergone spinal surgery must remain straight and turned as a unit. The Trendelenburg position is not indicated for the client who has undergone spinal surgery, nor should the client be lifted or encouraged to get up in a chair.

The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? a. "I must wear a medical alert bracelet stating that I am allergic to bee stings." b. "I need to carry epinephrine with me." c. "My spouse must learn how to give me an injection." d. "I am immune to bee stings now that I have had a reaction."

d RAT: More teaching is needed if the client states, "I am immune to bee stings now that I have had a reaction." No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe. The client should carry epinephrine (EpiPen) at all times and always wear a medical alert bracelet that states all allergies. Someone (spouse, neighbor, or family member) must learn how to give the client an injection in case the client is unable to self-administer the injection.

A client who sustained a recent cervical spinal cord injury reports feeling flushed. His blood pressure is 180/100. What is the nurse's best action at this time? a. Perform a bladder assessment. b. Insert an indwelling urinary catheter. c. Turn on a fan to cool off the patient. d. Place the client in a sitting position.

d RAT: The client is likely experiencing autonomic dysreflexia which is caused by an uncontrolled sympathetic nervous system response to one or more triggers, such as bladder distention, constipation, and temperature variations. However, until the nurse can assess and manage the cause, the best action is to make sure to sit the patient up to begin lowering the blood pressure and prevent further increase.

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? a. "Every injury is different, and it is too soon to have any real answers right now." b. "Only time will tell." c. "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." d. "Please request a meeting with the health care provider. I will help set that up."

d RAT: The nurse's best response to a family member of a client with a recent spinal cord injury is, "Please request a meeting with the primary health care provider. I will set that up." Questions concerning prognosis and potential for recovery would be referred to the primary health care provider. The nurse can help facilitate the meeting however. The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? a. Indication of allergies b. Level of consciousness c. Loss of sensation d. Patent airway

d RAT: The nursing priority when assessing a client with a spinal cord injury is a patent airway. Clients with injuries at or above T6 are at risk for respiratory complications. Assessing for a patent airway is essential. Asking the client about current medications and allergies is part of every trauma assessment. Assessing the level of consciousness utilizing the Glasgow Coma Score (GCS) is an important part of the trauma assessment. Determining the level of loss of sensation will be included in the neurological evaluation.

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? a. Nutritional therapy b. Occupational therapy c. Physical therapy d. Respiratory therapy

d RAT: To help prevent death for a client with spinal cord injury, collaboration with the Respiratory therapy team is a priority. A client with a cervical spinal cord injury is at risk for breathing problems including pneumonia and aspiration, resulting from the interruption of spinal innervation to the respiratory muscles. Collaboration with Respiratory therapy is crucial. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

What conditions would cause a decrease of fluid requirements for children? a. Burns b. Fever c. Vomiting d. Increased intracranial pressure

d RAT: When there is a risk of increased intracranial pressure, the child's fluid balance is carefully monitored to ensure that only required fluids are given. With burns, fever, and vomiting, the child loses fluids at a greater than expected rate. Supplemental fluids need to be given to avoid the risk of dehydration.

An alert, middle-aged client is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the "ABCs" for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? a. Raise the lower extremities. b. Start intravenous (IV) administration of normal saline. c. Reassure the client that appropriate interventions are being instituted. d. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.

d RAT: he most immediate priority is for the nurse to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Assessing respiratory status is the most important assessment priority. Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.

SHOCK The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? a. Hypotension b. Bradypnea c. Heart blocks d. Tachycardia

d Tachycardia is an early symptom of shock. Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal and not abnormally low. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock and are related to lack of oxygen to the heart.

SHOCK Which nurse would be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? a. The LPN/LVN who has 20 years of experience b. The new RN who recently finished orienting and is working independently with moderately complex clients c. The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago d. The RN with 2 years of experience in intensive care unit (ICU)

d The RN with 2 years ICU experience would be assigned to care for an intubated client with septic shock due to a MRSA infection. This RN with current intensive care experience who is not caring for a postoperative client is an appropriate nurse to care for this client. Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. A client who is experiencing septic shock is too complex for the new RN. Although the RN who is also caring for the post-CABG client is experienced, this assignment will put the post-CABG client at risk for MRSA infection.

SHOCK When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? a. Obtain IV access and hang prescribed fluid infusions. b. Apply the automatic blood pressure cuff. c. Assess level of consciousness and pupil reaction to light. d. Check the airway and respiratory status.

d The nurse's first action when caring for an obtunded client admitted with shock is to check the client's airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

SHOCK A client with hypovolemic shock has these vital signs: Temperature 97.9°F (36.6°C) Pulse 122 beats/min Blood pressure 86/48 mm Hg Respirations 24 breaths/min Urine output 20 mL for last 2 hours Skin cool and clammy. Which prescription order for this client does the nurse question? a. Dopamine (Intropin) 12 mcg/kg/min b. Dobutamine (Dobutrex) 5 mcg/kg/min c. Plasmanate 1 unit d. Bumetanide (Bumex) 1 mg IV

d The prescription order the nurse questions is Bumetanide (Bumex0 1 mg IV). A diuretic such as bumetanide will decrease blood volume in a client who is already hypovolemic. This order must be questioned because this is not an appropriate action to expand the client's blood volume. The orders other than Bumetanide are appropriate for improving blood pressure in shock and do not need to be questioned.

SHOCK Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? a. Oxygen saturation remains unchanged. b. Core body temperature has increased to 99°F (37.2°C). c. The client correctly states the month and the year. d. Serum lactate and the serum potassium levels are declining.

d. Serum lactate levels and serum potassium levels both rise when shock progresses and more tissues are metabolizing under anaerobic conditions. A decline in both values indicates that the client is responding to the current interventions for hypovolemic shock. Oxygen saturation staying the same suggests that the shock is not progressing at this time but does not indicate the interventions are correcting shock. The increase in body temperature is not great enough to indicate improvement or worsening of shock. The fact that the client can correctly state the month and the year by itself does not indicate improvement because information is not provided about his or her earlier cognition or level of consciousness.

Good Septic shock review videos

https://www.youtube.com/watch?v=-bt-H5VQl5E https://www.youtube.com/watch?v=DmJKEt0Iod8 https://www.youtube.com/watch?v=XuGPoQWzIco&t=515s