Exam (elaborations)
Capstone: Shock (NCLEX) Detailed Questions and Expert Answers
- Course
- Capstone: Shock
- Institution
- University Of California - San Francisco
Capstone: Shock (NCLEX) Detailed Questions and Expert Answers
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Capstone: Shock (NCLEX) Detailed Questionsand Expert Answers
A student is caring for a client who suffered massive blood loss after trauma. How
does the student correlate the blood loss with the client's mean arterial pressure
(MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP. - ANS B
Lower blood volume will decrease MAP. The other answers are not accurate.
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 they were last assessed 4 hours ago. What action by the nurse is
best?
a. Ask if the client needs pain medication.
b. Assess the client's tissue perfusion further.
c. Document the findings in the client's chart.
d. Increase the rate of the client's IV infusion. - ANS B
Signs of the earliest stage of shock are subtle and may manifest in slight increases
in heart rate, respiratory rate, or blood pressure. Even though these readings are
,not out of the normal range, the nurse should conduct a thorough assessment of
the client, focusing on indicators of perfusion. The client may need pain
medication, but this is not the priority at this time. Documentation should be done
thoroughly but is not the priority either. The nurse should not increase the rate of
the IV infusion without an order.
The nurse gets the hand-off report on four clients. Which client should 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 - ANS A
This client has a falling systolic blood pressure, rising diastolic blood pressure, and
narrowing pulse pressure, all of which may be indications of the progressive stage
of shock. The nurse should assess this client first. The client with the unchanged
oxygen saturation is stable at this point. Although the client with a change in pulse
has a slower rate, it is not an indicator of shock since the pulse is still within the
normal range; it may indicate the client's pain or anxiety has been relieved, or he
or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the
normal range, which is 30 mL/hr.
A nurse is caring for a client after surgery who is restless and apprehensive. The
unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they
are only slightly different from previous readings. What action does the nurse
delegate next to the UAP?
,a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the unaffected side.
d. Stay with the client and reassure him or her. - ANS B
Urine output changes are a sensitive early indicator of shock. The nurse should
delegate emptying the urinary catheter and measuring output to the UAP as a
baseline for hourly urine output measurements. The UAP cannot assess for pain.
Repositioning may or may not be effective for decreasing restlessness, but does
not take priority over physical assessments. Reassurance is a therapeutic nursing
action, but the nurse needs to do more in this situation.
A client is in shock and the nurse prepares to administer insulin for a blood glucose
reading of 208 mg/dL. 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 stress of this illness has made your spouse a diabetic. - ANS A
High glucose readings are common in shock, and best outcomes are the result of
treating them and maintaining glucose readings in the normal range. Medications
and IV solutions may raise blood glucose levels, but this is not the most accurate
answer. The stress of the illness has not made the client diabetic.
, A nurse caring for a client notes the following assessments: white blood cell count
3800/mm3, blood glucose level 198 mg/dL, 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 health care provider immediately.
d. Prepare to administer insulin per sliding scale. - ANS C
This client has several indicators of sepsis with systemic inflammatory response.
The nurse should notify the health care provider immediately. Documentation
needs to be thorough but does not take priority. The client may appreciate warm
blankets, but comfort measures do not take priority. The client may or may not
need insulin.
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. - ANS B
Preventing dehydration in older adults is important because the age-related
decrease in the thirst mechanism makes them prone to dehydration. Having older
adults drink fluids on a regular schedule will help keep them hydrated without the
influence of thirst (or lack of thirst). Telling clients not to get dehydrated is
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