408 AH 2 Final Exam

Which of the following clinical manifestations occur in cardiogenic shock? a. Blood pressure falls b. Skin is dry c. Urine output increases d. Quick capillary refill

a. Blood pressure falls

Which drug is a vasodilator used in the treatment of shock? a. Dobutamine b. Nitroglycerin c. Norepinephrine d. Dopamine

b. Nitroglycerin

A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia? Select all that apply. a. Nausea and vomiting b. Diarrhea c. Frequent infections d. Fatigue from anemia e. Easy bruising

c, d, e

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a. Isotonic enteral nutrition every 6 hours b. A full liquid diet c. An infusion of crystalloids at an increased rate of flow d. A continuous infusion of total parenteral nutrition

d. A continuous infusion of total parenteral nutrition

A client with suspected multiple myeloma is reporting back pain. What is the PRIORITY nursing action? a. have the client lie on a hard surface b. have the client rest c. encourage ambulation d. send the client for a spinal x-ray

d. send the client for a spinal x-ray

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is MOST appropriate for the nurse to implement? a. Begin a continuous IV infusion of insulin per protocol. b. Administer recombinant human activated protein C (rhAPC) as prescribed. c. Initiate enteral feedings as prescribed. d. Administer norepinephrine as prescribed.

d. Administer norepinephrine as prescribed.

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? a. kidneys b. lungs c. liver d. brain

d. brain

When a client is in the compensatory stage of shock, which symptom occurs? a. Tachycardia b. Bradycardia c. Urine output of 45 mL/hr d. Respiratory acidosis

a. Tachycardia

Which type of shock occurs from an antigen-antibody response? a. anaphylactic b. septic c. neurogenic d. cardiogenic

a. anaphylactic

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage? a. Dextran b. Albumin c. Hypertonic saline d. Lactated Ringer solution

b. Albumin

Morphine sulfate has which of the following effects on the body? a. Increases preload b. Reduces preload c. No effect on preload or afterload d. Increases afterload

b. Reduces preload

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition? a. 500 mL b. 400 mL c. 600 mL d. 300 mL

d. 300 mL

At what point in shock does metabolic acidosis occur? a. Late b. Irreversible c. Early d. Decompensation (Progressive)

d. Decompensation (Progressive)

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: a. Arrhythmias. b. A myocardial infarction. c. Cardiomyopathies. d. Valvular damage.

b. A myocardial infarction.

A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock? a. Cool, moist skin b. HR, 48 bpm; BP, 90/60 mm Hg c. HR, 120 bpm; BP, 88/58 mm Hg d. Shortness of breath

b. HR, 48 bpm; BP, 90/60 mm Hg

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? a. Slow the heart rate b. Increase the force of myocardial contraction c. Dilate the bronchial tree d. Depress the central nervous system

b. Increase the force of myocardial contraction

Which statement indicates the client understands teaching about induction therapy for leukemia? a. "I will start slowly with medication treatment." b. "I know I can never be cured." c. "I will be in the hospital for several weeks." d. "I will need to come every week for treatment."

c. "I will be in the hospital for several weeks."

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? a. Carcinogenic b. Obstructive c. Distributive d. Hypovolemic

c. Distributive

Which positioning strategy should be used for the client diagnosed with hypovolemic shock? a. supine b. semi-fowler's c. modified trendelenburg d. prone

c. modified trendelenburg

Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? a. Provide a clear liquid, low-sodium diet. b. Put on a mask, gown, and gloves when entering the client's room. c. Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding. d. Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.

d. Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.

Clinical characteristics of neurogenic shock are noted by which type of stimulation? a. Cerebral b. Sympathetic c. Endocrine d. Parasympathetic

d. Parasympathetic

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) a. Vital signs b. Mental status c. Visual acuity d. Ability to perform range of motion exercises e. Urinary output

a, b, e

A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply. a. antacids b. promotility agents c. H2 blockers d. proteases e. proton pump inhibitors

a, c, e

Which pulse pressure indicates shock? a. 90/70 mm HG b. 130/80 mm HG c. 120/90 mm HG d. 100/60 mm HG

a. 90/70 mm HG

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? a. A weak and thready pulse b. A rapid, bounding pulse c. A slow but steady pulse d. A slow and imperceptible pulse

b. A rapid, bounding pulse

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. a. Assess the client who is at risk for shock. b. Monitor for changes in vital signs. c. Administer prophylactic packed red blood cells to clients at risk for shock. d. Administer intravenous fluids. e. Administer vasoconstrictive medications to clients at risk for shock.

a, b, d

A nurse assesses a client who has been diagnosed with DIC. Which indicators are consistent with this diagnosis? Select all that apply. a. cyanosis in the extremities b. capillary refill time <3 seconds c. dyspnea and hypoxia d. increased breath sounds e. increased BUN and creatinine f. polyuria

a, c, e

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. a. 60 mmHg b. 70 mmHg c. 90 mmHg d. 80 mmHg

a. 60 mmHg MAP is cardiac output x peripheral resistance. The body must exceed 65 mmHg MAP for cells to receive oxygen and nutrients

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a. Aorta b. Radial artery c. Brachial artery d. Right ventricular wall

a. Aorta

A nurse prepares a client for a bone marrow biopsy who is suspected of having acute myeloid leukemia. What results from the bone marrow biopsy does the nurse expect? a. Excess of immature leukocytes b. Deficiency of neutrophils c. Deficiency of erythrocytes d. Excess of immature erythrocytes

a. Excess of immature leukocytes

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? a. The difference between the systolic and diastolic pressure b. The difference between an upper extremity and lower extremity blood pressure c. The difference between the arterial and venous blood pressure d. The difference between an apical and radial pulse

a. The difference between the systolic and diastolic pressure

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess a. lung sounds b. mental status c. skin perfusion d. bowel sounds

a. lung sounds

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? a. organ damage b. unsteady gait c. weight loss d. liver dysfunction

a. organ damage

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete FIRST? a. Type and cross match b. 100% oxygen via a nonrebreather mask c. C-spine x-rays d. Two large-bore IVs and begin crystalloid fluids

b. 100% oxygen via a nonrebreather mask

Which colloid is expensive but rapidly expands plasma volume? a. Lactated Ringer solution b. Albumin c. Dextran d. Hypertonic saline

b. Albumin

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance? a. Cover the client with a blanket. b. Elevate the legs higher than the heart. c. Place a cool compress on head. d. Shake the client to arouse.

b. Elevate the legs higher than the heart.

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as a. Compensatory b. Progressive c. Hypovolemic d. Neurogenic

b. Progressive

The nurse is caring for a client in the compensation stage of shock. One of the body's mechanisms of compensation in this stage of shock is the action of the renin-angiotensin-aldosterone system. What does this system do? a. Increases catecholamine secretion b. Restores blood pressure c. Decreases peripheral blood flow d. Increases the production of antidiuretic hormone

b. Restores blood pressure

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: a. breath sounds b. blood pressure c. heart rate d. renal output

b. blood pressure

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? a. high b. low c. unable to measure d. normal

b. low

A nurse is providing teaching to a client who will undergo chemotherapy and radiation prior to hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia (AML). What statement will the nurse use to describe the purpose of the chemotherapy and radiation? a. "These therapies shrink your tumor to ensure the stem cell transplant is more effective." b. "These therapies decrease your immune system to decrease the risk of allergic reaction." c. "These therapies destroy the ability of your body to produce blood cells inside your bone marrow." d. "These therapies destroy the bone marrow in an effort to shrink it and decrease your pain."

c. "These therapies destroy the ability of your body to produce blood cells inside your bone marrow."

A client who is undergoing chemotherapy for AML reports pain in the low back. What is the nurse's FIRST action? a. refer the client to a chiropractor b. place heating pads on the client's back c. assess renal function d. administer pain medication as ordered

c. assess renal function

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? a. neurogenic b. anaphylactic c. septic d. cardiogenic

c. septic

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? a. Within normal limits b. Thready c. Palpable d. 24

d. 24

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply. a. Obstructive shock; kidney stone b. Neurogenic shock; diabetes c. Cardiogenic shock; myocardial infarction d. Hypovolemic shock; blood loss e. Septic shock; infection f. Anaphylactic shock; nut allergy

c, d, e, f

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? a. Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage. b. The renin-angiotensin-aldosterone system fails in the compensation stage. c. Shock begins in the decompensation stage. d. In the compensation stage, catecholamines are released.

d. In the compensation stage, catecholamines are released.

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient? a. The patient has developed a stress ulcer that is bleeding. b. The patient is having a reaction to the vasoconstricting medications. c. The patient has a tumor in the esophagus. d. The patient has bleeding esophageal varices.

a. The patient has developed a stress ulcer that is bleeding.

The nurse is interacting with a family that has been caring for a client with cancer for several months. What are the best interventions to assist in relieving caregiver stress in this family? Select all that apply. a. Suggest the prescription of antianxiety medications. b. Suggest the family go to church more often. c. Suggest support for household maintenance. d. Allow family members to express feelings. e. Educate the family about medications and side effects.

c, d, e

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? a. Trendelenburg b. Semi-Fowler's c. Supine d. Modified Trendelenburg

d. Modified Trendelenburg

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? a. Increase in diastolic pressure b. Increase in systolic blood pressure c. Decrease in respiratory rate d. Narrowed pulse pressure

d. Narrowed pulse pressure

The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in? a. Irreversible b. Compensatory c. Initial d. Progressive

d. Progressive

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? a. Administer prophylactic antibiotics for all patients at risk. b. Have patients wear masks in the health care facility. c. Insert indwelling catheters for incontinent patients. d. Use strict hand hygiene techniques.

d. Use strict hand hygiene techniques.