Chapter 31: Critical Care of Patients with Shock

A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client's mean arterial pressure (MAP)?

a. It causes vasoconstriction and increases map

b. Lower blood volume lowers MAP.

c. There is no direct correlation to MAP.

d. It raises cardiac output and MAP.

b. Lower blood volume lowers MAP

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best?

a. Ask if the client needs pain medication.

b. Assess using the MEWS score.

c. Document the findings in the client's chart.

d. Increase the rate of the client's IV infusion.

b. Assess using the MEWS score.

The nurse gets the hand-off report on four clients. Which client would the nurse assess first?

a. Client with a blood pressure change of 128/74 to 110/88 mm Hg

b. Client with oxygen saturation unchanged at 94%

c. Client with a pulse change of 100 to 88 beats/min

d. Client with urine output of 40 mL/hr for the last 2 hours

a. Client with a blood pressure change of 128/74 to 110/88 mm Hg

A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP?

a. Assess the client for pain or discomfort.

b. Measure urine output from the catheter.

c. Reposition the client to the side.

d. Stay with the client and reassure him or her.

b. Measure urine output from the catheter.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?

a. "High glucose is common in shock and needs to be treated."

b. "Some of the medications we are giving are to raise blood sugar."

c. "The IV solution has lots of glucose, which raises blood sugar."

d "the dress of this illness has made your spouse a diabetic"

a. "High glucose is common in shock and needs to be treated."

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3 (3.8 109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6° C). What action by the nurse takes priority?

a. Document the findings in the client's chart.

b. Give the client warmed blankets for comfort.

c. Notify the primary health care provider immediately.

d. Prepare to administer insulin per sliding scale.

c. Notify the primary health care provider immediately.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?

a. Do not get dehydrated in warm weather.

b. Drink fluids on a regular schedule.

c. Seek attention for any lacerations.

d. Take medications as prescribed.

b. Drink fluids on a regular schedule.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?

a. Apply direct pressure to the bleeding.

b. Ensure the client has a patent airway.

c. Obtain a pulse oximetry reading

d. Start two large-bore IV catheters.

b. Ensure the client has a patent airway.

A client is receiving norepinephrine for shock. What assessment finding best indicates a therapeutic effect from this drug?

a. Alert and oriented, answering questions

b. Client denies chest pain or chest pressure

c. IV site without redness or swelling

d. Urine output of 30 mL/hr for 2 hours

a. Alert and oriented, answering questions

A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome (MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the nurse causes the charge nurse to intervene?

a. Assessing the IV site before giving the drug

b. Obtaining a programmable ("smart") IV pump

c. Removing the IV bag from the brown plastic cover

d. Taking and recording a baseline set of vital signs

c. Removing the IV bag from the brown plastic cover

A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following:

Respiratory rate: 10 breaths/min

Pulse: 136 beats/min

Blood pressure: 92/78 mm Hg

Level of consciousness: responds to voice

Temperature: 101.5° F (38.5° C)

Urine output for the last 2 hours: 40 mL/hr.

What action by the nurse is best?

a. Transfer the client to the Intensive Care Unit.

b. Continue monitoring every 30 minutes.

c. Notify the unit charge nurse immediately.

d. Call the Rapid Response Team

d. Call the Rapid Response Team

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the primary health care provider?

a. Creatinine: 0.9 mg/dL (68.6 mcmol/L)

b. Lactate: 5.4 mg/dL (6 mmol/L)

c. Sodium: 150 mEq/L (150 mmol/L)

d. White blood cell count: 11,000/mm3 (11 109/L)

b. Lactate: 5.4 mg/dL (6 mmol/L)

A nurse receives hand-off report from the emergency department on a new admission suspected of having septic shock. The client's SOFA score is 3. What action by the nurse is best?

a. Plan to calculate a full SOFA score on arrival.

b. Contact respiratory therapy about ventilator setup.

c. Arrange protective precautions to be implemented.

d. Call the hospital chaplain to support the family

a. Plan to calculate a full SOFA score on arrival.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

a. "All my friends and neighbors are planning a party for me."

b. "I hope I can get my water turned back on when I get home."

c. "I am going to have my daughter scoop the cat litter box."

d. "My grandkids are so excited to have me coming home!"

b. "I hope I can get my water turned back on when I get home."

A client with MODS has been started on dobutamine. What assessment finding requires the nurse to communicate with the primary health care provider immediately?

a. Blood pressure of 98/68 mm Hg

b. Pedal pulses 1+/4+ bilaterally

c. Report of chest heaviness

d. Urine output of 32 mL/hr

c. Report of chest heaviness

The nurse studying shock understands that the common signs and symptoms of this condition are directly related to which problems? (Select all that apply.)

a. Anaerobic metabolism

b. Hyperglycemia

c. Hypotension

d. Impaired renal perfusion

e. Increased systemic perfusion

a. Anaerobic metabolism

c. Hypotension

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.)

a. Assessing and identifying clients at risk

b. Monitoring the daily white blood cell count

c. Performing proper hand hygiene

d. Removing invasive lines as soon as possible

e. Using aseptic technique during procedures

a. Assessing and identifying clients at risk

c. Performing proper hand hygiene

d. Removing invasive lines as soon as possible

e. Using aseptic technique during procedures

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what risk factors would the nurse assess? (Select all that apply.)

a. Altered mobility/immobility

b. Decreased thirst response

c. Diminished immune response

d. Malnutrition

e. Overhydration

f. Use of diuretics

a. Altered mobility/immobility

b. Decreased thirst response

c. Diminished immune response

d. Malnutrition

f. Use of diuretics

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

a. Bringing the client warm blankets

b. Giving the client hot tea to drink

c. Massaging the client's painful legs

d. Reorienting the client as needed

e. Sitting with the client for reassurance

a. Bringing the client warm blankets

b. Giving the client hot tea to drink

d. Reorienting the client as needed

e. Sitting with the client for reassurance

The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.)

a. Administer antibiotics.

b. Draw serum lactate levels.

c. Infuse vasopressors.

d. Measure central venous pressure.

e. Obtain blood cultures.

f. Administer rapid bolus of IV crystalloids.

a. Administer antibiotics.

b. Draw serum lactate levels.

c. Infuse vasopressors.

e. Obtain blood cultures.

f. Administer rapid bolus of IV crystalloids.