MSS Ch 15: Shock

Question 1

The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client’s pulse pressure has occurred between the two readings? ______

Answer 1

16 mm Hg pulse pressure.

The pulse pressure is the systolic BP minus the diastolic BP.
100 􏱀 60 = 40 mm Hg pulse pressure in first BP reading
88 􏱀 64 = 24 mm Hg pulse pressure in second reading
40 􏱀 24 = 16 mm Hg pulse pressure narrowing.
A narrowing or decreased pulse pressure is an earlier indicator of shock than a decrease in systolic blood pressure.

Question 2

The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?

1. Start an IV with an 18-gauge catheter.
2. Administer dopamine intravenous infusion.
3. Obtain arterial blood gases (ABGs).
4. Insert an indwelling urinary catheter.

Answer 2

1. There are many types of shock, but the one common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock.
2. This blood pressure does not require dopamine; fluid resuscitation is first.
3. The client may need ABGs monitored, but this is not the first intervention.
4. An indwelling catheter may need to be inserted for accurate measurement of out- put, but it is not the first intervention.

Question 3

The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?

1. Vital signs T 100.4 ̊F, P 104, R 26, and BP 102/60.
2. A white blood cell count of 18,000/mm3.
3. A urinary output of 90 mL in the last four (4) hours.
4. The client complains of being thirsty.

Answer 3

1. These vital signs are expected in a client with septic shock.
2. An elevated WBC count indicates an infec- tion, which is the definition of sepsis.
3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last four (4) hours indicates impaired renal perfusion, which is a sign of worsening shock and warrants immediate intervention.
4. The client being thirsty is not an uncom- mon complaint for a client in septic shock.

Question 4

The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority?

1. Provide clear liquid diet.
2. Initiate IV antibiotic therapy.
3. Obtain a STAT chest x-ray.
4. Perform hourly glucometer checks.

Answer 4

1. The client’s diet is not priority when tran- scribing orders.
2. An IV antibiotic is the priority medica- tion for the client with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order.
3. Diagnostic tests are important but not priority over intervening in a potentially life-threatening situation such as septic shock.
4. There is no indication this client has diabetes in the stem of the question, and glucose levels are not associated with signs/symptoms of septicemia.

Question 5

The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?

1. Cool moist skin.
2. Bradycardia.
3. Wheezing.
4. Decreased bowel sounds.

Answer 5

1. The client diagnosed with neurogenic shock will have dry, warm skin, rather than cool, moist skin as seen in hypovolemic shock.
2. The client will have bradycardia instead of tachycardia, which is seen in other forms of shock.
3. Wheezing is associated with anaphylactic shock.
4. Decreased bowel sounds occur in the hyperdynamic phase of septic shock.

Question 6

The nurse in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement?

1. Ask the client about drug allergies.
2. Obtain a sterile sputum specimen.
3. Have the client wait for 30 minutes.
4. Place a warm washcloth on the client’s left hip.

Answer 6

1. It is too late to ask the client about drug al- lergies because the medication has already been administered.
2. Obtaining a specimen after the antibiotic has been initiated will skew the culture and sensitivity results. It must be obtained be- fore the antibiotic is started.
3. Anytime a nurse administers a medica- tion for the first time, the client should be observed for a possible anaphylactic reaction, especially with antibiotics.
4. The client is being discharged and the nurse can encourage the client to do this at home, but it is not appropriate to do in the emergency room.

Question 7

The nurse caring for a client with sepsis writes the client diagnosis of “alteration in comfort R/T chills and fever.” Which intervention should be included in the plan of care? 1. Ambulate the client in the hallway every shift.

2. Monitor urinalysis, creatinine level, and BUN level.
3. Apply sequential compression devices to the lower extremities.
4. Administer an antipyretic medication every four (4) hours PRN.

Answer 7

1. Ambulating the client in the hall will not address the etiology of the client’s chills and fever; in fact, this could increase the client’s discomfort.
2. Monitoring these laboratory data does not address the etiology of the client’s diagnosis.
3. Sequential compression devices help prevent deep vein thrombosis.
4. Antipyretic medication will help decrease the client’s fever, which directly addresses the etiology of the client’s nursing diagnosis.

Question 8

The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?

1. The UAP places a urine specimen in a biohazard bag in the hallway.
2. The UAP uses the alcohol foam hand cleanser after removing gloves.
3. The UAP puts soiled linen in a plastic bag in the client’s room.
4. The UAP obtains a disposable stethoscope for a client in an isolation room.

Answer 8

1. Specimens should be put into biohazard bags prior to leaving the client’s room.
2. This is the appropriate way to clean hands and does not warrant intervention.
3. This is the appropriate way to dispose of soiled linens and does not warrant intervention.
4. Taking a stethoscope from a client who is in isolation to another room is a violation of infection-control principles.

Question 9

The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?

1. Cardiogenic shock.
2. Hypovolemic shock.
3. Neurogenic shock.
4. Septic shock.

Answer 9

1. Cardiogenic shock occurs when the heart’s ability to contract and pump blood is impaired and the supply of oxygen to the heart and tissues is inadequate, such as occurs in myocardial infarction or valvular damage.
2. These client’s signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client’s taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stom- ach, which increases the risk of develop- ing ulcers, which can erode the stomach lining and lead to hemorrhaging.
3. In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. It can result from the depressant action of medication or lack of glucose.
4. Septic shock is a type of circulatory shock caused by widespread infection.

Question 10

The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?

1. Monitor the client’s telemetry.
2. Turn the client every two (2) hours.
3. Administer oxygen via nasal cannula.
4. Place the client in the Trendelenburg position.

Answer 10

1. Monitoring the telemetry will not prevent cardiogenic shock. It might help identify changes in the hemodynamics of the heart, but it does not prevent anything from occurring.
2. Turning the client every two (2) hours will help prevent pressure ulcers, but it will do nothing to prevent cardiogenic shock.
3. Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock.
4. Placing the client’s head below the heart will not prevent cardiogenic shock. This position can be used when a client is in hypovolemic shock.

Question 11

The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider?

1. The client’s potassium level is 3.8 mEq/L.
2. The urine culture indicates high sensitivity to the antibiotic.
3. The client’s pulse oximeter reading is 94%.
4. The culture and sensitivity is resistant to the client’s antibiotic.

Answer 11

1. This is a normal potassium level (3.5 to 5.5 mEq/L); therefore, the nurse does not need to notify the HCP.
2. A culture result showing a high sensitivity to an antibiotic indicates this is the antibiotic the client should be receiving.
3. A pulse oximeter reading of greater than 93% indicates the client is adequately oxygenated.
4. A sensitivity report indicating a resist- ance to the antibiotic being adminis- tered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organ- ism, and the HCP needs to be notified so the antibiotic can be changed.

Question 12

The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing?

1. The hypodynamic phase.
2. The compensatory phase.
3. The hyperdynamic phase. 4. The progressive phase.

Answer 12

1. The hypodynamic phase is the last and irreversible phase of septic shock, characterized by low cardiac output with vasoconstriction. It reflects the body’s effort to compensate for hypovolemia caused by the loss of intravascular volume through the capillaries.
2. In the compensatory phase of shock, the heart rate, blood pressure, and respiratory rate are within normal limits, but the skin may be cold and clammy and urinary out- put may be decreased. However, this is the first phase of all types of shock and is not specific to septic shock.
3. The hyperdynamic phase, the first phase of septic shock, is characterized by a high cardiac output with systemic vasodilation. The BP may remain within normal limits, but the heart rate increases to tachycardia and the client becomes febrile.
4. The progressive phase is the second phase of all shocks. It occurs when the systolic BP decreases to less than 80 to 90 mm Hg, the heart rate increases to greater than 150 beats per minutes, and the skin becomes mottled.