SHOCK UNIT 2

A client has been involved in a shooting and is brought to the emergency department with profuse bleeding from the abdomen. Place each intervention in order of priority. All options must be used. 1Assess all vital signs, including oxygen saturation. 2Control the pain from the gunshot wound. 3Infuse intravenous fluids to prevent shock. 4Maintain NPO in anticipation of surgery. 5Assess the chest for evidence of other injuries.

1, 3, 5, 2, 4

A client with diabetes is in the emergency department because of vomiting, diarrhea, and weight loss of 8 pounds over 2 days. Vital signs taken by the triage nurse indicate the client is in hypovolemic shock. Place the nurse's steps in the correct order. 1Assess the capillary blood glucose level. 2Initiate an intravenous (IV) site and prescribed IV fluids. 3Place the client in the modified Trendelenburg position. 4Collect a stool specimen for culture.

3, 2, 1, 4

A client admitted with septic shock has a blood pressure of 70/46 mm Hg, pulse 125 bpm, respirations 30 breaths/min, temperature 103°F (39.4°C), and blood glucose 266 mg/dL (14.76 mmol/L). Which intervention prescribed by the health care provider should the nurse implement first? Administer acetaminophen 650 mg rectally. Administer an insulin drip to maintain blood glucose at 110 to 150 mg/dL (6.11 to 8.32 mmol/L). Administer norepinephrine to keep systolic blood pressure >90 mm Hg. Administer a fluid bolus of normal saline IV at 500 mL/hr.

administer a fluid bolus of NS IV at 500mL/hr

A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine the effectiveness of therapy? Assess the client's skin turgor. Assess the client's mucous membrane. Assess deep tendon reflexes. Monitor intake and output.

assess deep tendon reflexes

A 10-year-old boy with congenital heart disease is in shock. Which nursing intervention would be most appropriate for this child? Monitoring urine output with a goal of 1 to 2 ml/kg/hour. Palpating for pulses and capillary refill. Assessing for pulmonary edema from fluid overload. Assessing for changes in mental status and alertness.

assessing for pulmonary edema from fluid overload

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order? blood chemistry of serum lactate intravenous dextrose in water at 75 mL/hour vital signs every 4 hours blood chemistry of AST, alkaline phosphates

blood chemistry of serum lactate

The nurse is assessing a client who is suspected of having acute postinfectious glomerulonephritis. Which assessment(s) will the nurse prioritize as related to acute postinfectious glomerulonephritis? Select all that apply. blood pressure edema history of recent illnesses urinary frequency and dysuria acute flank pain urine output and appearance

blood pressure edema history of recent illnesses urine output and appearance

A nurse is caring for a client receiving I.V. magnesium sulfate. Which drug is the antidote for magnesium toxicity? Rohm(D) immune globulin calcium gluconate hydralazine/hydralazine naloxone

calcium gluconate

The nurse is caring for a 9-month-old infant with severe diarrhea that has lasted 3 days and who displays evidence of severe dehydration with increased heart rate and decreased blood pressure. What nursing assessment is a priority? willingness to drink intake and output balance capillary refill time skin turgor

capillary refill time

The nurse is working with a client admitted with shock in a critical care unit. What assessment findings indicate fluid volume deficit and would need to be reported to the health care provider? Select all that apply. mean arterial pressure of 75 mm Hg oxygen saturation of 65% central venous pressure 1 mm Hg urine output 40 mL for the last two hours heart rate 136 beats per minute

central venous pressure 1 mm Hg urine output 40 mL for the last two hours heart rate 136 bpm

A postoperative client is experiencing urinary retention, and the nurse is inserting an indwelling catheter. Immediately, 750 mL of clear yellow urine is collected in the drainage bag. What should the nurse do next? Pinch the catheter to slow the flow of urine. Clamp the catheter for 20 minutes. Continue to drain the bladder until empty. Remove the catheter and document the output.

clamp the catheter for 20 minutes because taking that much urine from someone in such a short amount of time puts them at risk for hypovolemic shock

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.) Crackles Compensatory respiratory acidosis A heart rate >100 bpm Respirations <15 breaths/min Lethargy and mental confusion

crackles a heart rate>100bpm lethargy and mental confusion

The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. Drop in systolic blood pressure of ≥40 mm Hg from baselines Mean arterial pressure (MAP) of ˂65 mm Hg Serum lactate >4 mmol/L Exaggerated response to vasoactive medications Hypotension that responds to bolus fluid resuscitation

drop in systolic blood pressure of > 40 mm hG from baseline mean arterial pressure of 65 serum lactate > 4 mmol/L

A critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock? Aggressive antibiotic therapy Administration of hypertonic IV fluids Early provision of nutritional support Aggressive hypoglycemic control

early provision of nutritional support

A patient has been admitted to the hospital with acute nephritic syndrome. They experienced sudden onset of hematuria. The nurse is looking at their lab work and have noted a decreased glomerular filtration rate (GFR). The nurse should assess their patient for which signs/symptoms related to a decreased GFR? Select all that apply. Edema in face and extremities. Dark urine color. Elevated blood pressure. Severe flank pain Urine smelling odoriferous.

edema in facce and extremities elevated BP

An older adult client experiencing anaphylaxis is administered intramuscular epinephrine. For what adverse effect(s) of epinephrine will the nurse assess? Select all that apply. hypertension oliguria bronchoconstriction angina bradycardia

hypertension oliguria angina

The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.) Hypoperfusion of tissues Activation of the inflammatory response Increase in cellular Activity Must produce energy through anaerobic metabolism Increased intravascular volume

hypoperfusion of tissues activation of inflammatory response must produme energy through anaerobic metabolism

A client is admitted from the emergency department reporting severe right lower quadrant abdominal pain and an elevated white blood cell count and a low grade fever. The nurse continues to monitor the patient while waiting for the physician. The nurse will identify the following as a major concern: vomiting. a low sedimentation rate on the patients lab report. hypotension. increased pain.

hypotension

The nurse is caring for a client experiencing a systemic anaphylactic reaction. Which assessment findings correlate with this diagnosis? Select all that apply. Hypotension Vomiting and abdominal cramps Hypertension Bronchospasm and respiratory distress Laryngeal edema and obstruction

hypotension vomiting and abdominal cramps bronchospasm and respiratory distress laryngeal edema and obstruction

When evaluating a pregnant client's knowledge of symptoms to report immediately, which statement indicates to the nurse that the client understands the information given to her? "Nausea should be reported immediately." "I'll report increased frequency of urination." "If I have blurred or double vision, I should call the clinic immediately." "If I feel tired after resting, I should report it immediately."

if i have blurred or double vision, i should call the clinic immediately

A client is receiving IV norepinephrine for treatment of shock. What is the goal of administration? Increased cardiac contractibility Increased cardiac output Increased heart rate Increased blood pressure

increased BP

The nurse prepares to administer a selective alpha-adrenergic agonist medication to a client diagnosed with shock. What would the nurse consider to be therapeutic or desired effects based upon the characteristics of the prescribed medication? Select all that apply. Hypoglycemia Bronchodilation Bradycardia Increased blood pressure Increased cardiac output

increased BP Increased cardiac output

A nurse is teaching a student about nephrotic syndrome. Which statement(s) about the pathogenesis of nephrotic syndrome is accurate and should be included in the education? Select all that apply. The presence of glomerular immunoglobulin A immune complex deposits occur. Increased glomerular membrane permeability allow proteins to escape from the plasma into glomerular filtrate. There is an insidious onset beginning with hematuria and mild hypertension. Loss of colloidal osmotic pressure causes generalized edema. Massive proteinuria is a result of the increased permeability.

increased glomerular membrane permeability allow proteins to escape from the plasma into glomerular loss of colloidal osmotic pressure causes generalized edema massive proteinuria is a result of the increased permeability

Which clinical manifestations would lead the nurse to suspect that a client with renal failure is developing uremia? Select all that apply. Blood in urine. Lethargy and confusion. Urine smell in the stool. Weakness and fatigue. Extreme itching.

lethargy and confusion weakness and fatigue extreme itching

A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure? rapid respirations constipation bradycardia low urine output

low urine output

A nurse is providing care to a child who was involved in a severe car accident. The child sustained significant internal injuries and blood loss. The child has developed refractory shock. Which action is most important for the nurse take? Ask the health care provider to consider changing the child's medications. Make arrangements for the parents to meet with the health care team. Increase the rate on the child's intravenous fluid infusion. Monitor the child closely for any further changes in the child's condition.

make arrangements for the parents to meet with the health care team

A child is experiencing shock. Which assessment is essential for the nurse to complete to tell if the child is able to compensate? Monitor the respiratory status. Monitor the heart rate. Monitor the blood pressure. Monitor the neurological status.

monitor BP

A RN is delegating client care responsibilities to a licensed practical/vocational nurse (LPN/VN). Which nursing responsibilities would be appropriate to delegate to the LPN/VN? Select all that apply. Obtain a bedside glucose specimen test at 1100. Changing the client's decubitus foot ulcer dressing. Administering the client's Lasix 80mg IVP stat. Reinforcing the teaching of proper diabetic diet. Assessing the client's swallowing ability before feeding.

obtain a bedside glucose specimen test at 1100 changing the client's decubitus foot ulcer dressing reinforcing the teaching of proper diabetic diet

Hypovolemic shock is characterized by a loss of blood volume or extracellular fluid. Administering which of the following would manage a client with hypovolemic shock? Select all that apply. Packed red blood cells Plasma volume expanders Vasoconstrictor drugs Crystalloids Whole blood

packed red blood cells plasma volume expanders crystalloids whole blood

The client was admitted to the Emergency Department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would the nurse assess for? Postural hypotension Malabsorption disorders Reduced urine output Fatigue

reduced urine output

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. Reports of chest pain Decreases in liver enzymes Ecchymoses and petechiae Loss in consciousness Increased paCO² levels

reports of chest pain ecchymoses and petechiae loss in consciousness increased paCO2 levels

The nurse is caring for a woman who delivered via a cesarean birth approximately 16 hours earlier. Which assessment finding should the nurse prioritize? gradually decreasing temperature and pulse rate steadily decreasing volume of urine excessive diaphoresis uterine height at umbilicus

steadily decreasing volume of urine

After a long bout with vomiting and diarrhea, a client is suspected to be in hypovolemic shock. Which clinical manifestations will the nurse assess that substantiates this diagnosis? Select all that apply. Slow, shallow respiration Tachycardia Acidosis Apprehension Warm, dry skin

tachycardia acidosis apprehension

The nurse receives shift hand-off on an assigned client who had a surgical procedure. What objective assessment suggests that the client may be developing sepsis and is at risk for septic shock? Select all that apply. pulse rate of 32 beats per minute temperature increase tachypnea 32 mL of urine in 2 hours blood pressure decrease

temperature increases tachypnea 32 mL of urine in 2 hours blood pressure decreases

The physician is treating a client in lactic acidosis following cardiac arrest. Which treatment will be effective in correcting this acidosis? Administration of potassium chloride Administration of sodium bicarbonate Treatments to improve tissue perfusion and oxygenation Hypoventilation

treatments to improve tissue perfusion and oxygenation

In circulatory shock, the adrenergic (or sympathetic) nervous system is activated. The nurse knows that stimulation of beta-2 adrenergic receptors will result in which responses? Select all that apply. Vasodilation of the skeletal muscle vascular bed Dilation of the bronchioles Vasoconstriction in many vascular beds Increased force of myocardial contraction Increase in heart rate

vasodilation of the skeletal muscle vascular bed dilation of the bronchioles