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...
Shock, Sepsis & Multiple Organ
Dysfunction NCLEX fully solved
& updated(100% accuracy)
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. - answer 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. - answer 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 - answer
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. - answer 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. -
answer 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. - answer 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. - answer 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 important, but not the best
answer because it doesn't give them the tools to prevent it from
occurring. Older adults should seek attention for lacerations, but
this is not as important an issue as staying hydrated. Taking
medications as prescribed may or may not be related to hydration.
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 consent for emergency surgery.
d. Start two large-bore IV catheters. - answer B ~ Airway is the
priority, followed by breathing and circulation (IVs and direct
pressure). Obtaining consent is done by the physician.
A client is receiving norepinephrine (Levophed) for shock. What
assessment finding best indicates a therapeutic effect from this
drug?
a. Alert & oriented, answering questions
b. Client denial of chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours - answer A ~ Normal
cognitive function is a good indicator that the client is receiving the
benefits of norepinephrine. The brain is very sensitive to changes in
oxygenation and perfusion. Norepinephrine can cause chest pain as
an adverse reaction, so the absence of chest pain does not indicate
therapeutic effect. The IV site is normal. The urine output is normal,
but only minimally so.
A student nurse is caring for a client who will be receiving sodium
nitroprusside (Nipride) via IV infusion. What action by the student
causes the registered nurse to intervene?
a. Assessing the IV site before giving the drug
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