Shock Prep U

Which pulse pressure indicates shock? 120/90 mm HG 90/70 mm HG 130/80 mm HG 100/60 mm HG

90/70 mm HG

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? Liver Kidneys Lungs Brain

Brain

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? Head injury Myocardial infarction Diabetes Multiple sclerosis

Head injury

The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? Anaphylactic Hypovolemic Neurogenic Cardiogenic

Hypovolemic

A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority? Give three doses of epinephrine. Administer two consecutive defibrillator shocks. Initiate cardiac compressions. Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR).

Initiate cardiac compressions.

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? Septic Anaphylactic Neurogenic Cardiogenic

Septic

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

The difference between the systolic and diastolic pressure

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? Modified Trendelenburg Trendelenburg Semi-Fowler's Supine

Modified Trendelenburg

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure? Respiratory alkalosis Myocardial depression Rapid, shallow respirations Lethargy and confusion

Myocardial depression

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Oxygen at 2 L/min by nasal cannula Morphine 2 mg intravenously NS at 60 mL/hr via an intravenous line Dopamine (Intropin) intravenous solution

Oxygen at 2 L/min by nasal cannula

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? Hormone antagonist drugs Antimetabolite drugs Adrenergic drugs Anticholinergic drugs

Adrenergic drugs

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is A young female adolescent who developed shock from tampon use during menses An older adult man with end-stage renal disease and an infected dialysis access site An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection A middle-aged woman with metastatic breast cancer and a BMI of 26

An older adult man with end-stage renal disease and an infected dialysis access site

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: Jugular venous distention Decreased pulse rate to 110 beats/minute Positive increase in the fluid balance ratio Vesicular breath sounds

Jugular venous distention

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. hemoglobin level. temperature. heart rate.

blood pressure.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in the brain. lungs. liver. kidneys.

lungs.

The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of: lethal arrhythmia. underlying heart disease. respiratory failure. neurologic trauma.

respiratory failure.