Exam (elaborations)

Nclex Questions for Shock - Critical Care

49 views 0 purchase

Course
Nclex

Institution
Nclex

What will the nurse identify as symptoms of hypovolemic shock in a patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Temperature of 97.6°F (36.4°C) 2. Restlessness 3. Decrease in blood pressure of ...

[Show more]

Preview 3 out of 19 pages

View example

Uploaded on August 2, 2023
Number of pages 19
Written in 2023/2024
Type Exam (elaborations)
Contains Questions & answers

nclex questions for shock critical care

CA$20.92

Also available in package deal from CA$72.89

Added

Add to cart Add to wishlist

100% satisfaction guarantee
Immediately available after payment
Both online and in PDF
No strings attached

Also available in package deal (1)

NCLEX

CA$ 103.17 CA$ 72.89 4 items

1. Exam (elaborations) - Nclex critical care nurse question
2. Exam (elaborations) - Nclex 285 exam 2 critical care/vent managment
3. Exam (elaborations) - Nclex questions for shock - critical care
4. Exam (elaborations) - Saunders nclex critical care
Show more

Nclex Questions for Shock - Critical Care

What will the nurse identify as symptoms of hypovolemic shock in a patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Temperature of 97.6°F (36.4°C)

2. Restlessness

3. Decrease in blood pressure of 20 mm Hg when the patient sits up

4. Capillary refill time greater than 3 seconds

5. Sinus bradycardia of 55 beats per minute - Correct Answer: 2,3,4

Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless
prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic
shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing
the core metabolic rate.

Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status.

Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock.

Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, capillary refill time will be reduced.

Rationale 5: Bradycardia is not present. The compensatory response is to increase the heart rate to
circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.

Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic
shock?

1. Serum sodium of 130 mEq/L (130 mmol/L)

2. Metabolic acidosis validated by arterial blood gases

3. Serum lactate of 3 mmol/L

4. SvO2 greater than 80% - Correct Answer: 2

Rationale 1: The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145
mEq/L, not reduced.

,Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate
deficit from decreased tissue perfusion.

Rationale 3: Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and
breakdown from decreased blood flow with hypovolemic shock.

Rationale 4: SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased
circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently
and decreased, not increased.

The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient
with:

1. Decreased cardiac output

2. Severe constipation, causing watery diarrhea

3. Ascites

4. Syndrome of inappropriate ADH (SIADH) - Correct Answer: 3

Rationale 1: Although ECG changes reflect the effectiveness of the heart's pumping when circulating the
blood, it is not a risk factor for hypovolemic shock, which reflects a decreased circulating volume from
either blood or fluid losses within the intravascular system.

Rationale 2: Severe constipation does not affect the circulating blood volume.

Rationale 3: Third spacing shifts move the fluids from the intravascular space into the interstitial space,
causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the
development of hypovolemic shock.

Rationale 4: Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might
cause cardiogenic shock, congestive heart failure, and pulmonary edema.

Which finding indicates that a patient is experiencing increased peripheral resistance and
vasoconstriction?

1. Strong bounding pulse with deep red coloring

2. Pale, cool extremities with decreased pulses

3. Increased venous engorgement with strong pulses

4. Faster than normal capillary refill time - Correct Answer: 2

Rationale 1: An increased blood supply would increase color and bounding pulses as seen with
vasodilation (blood engorgement) and is not present with increased peripheral resistance and
vasoconstriction.

, Rationale 2: Increased peripheral resistance causes the blood supply to decrease and results in
decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would
decrease in intensity with a decreased blood supply.

Rationale 3: Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses
would not be present with vasoconstriction from increased peripheral resistance.

Rationale 4: Capillary refill times are delayed or slowed due to decreased blood flow through the vessels
caused by the vasoconstriction from increased peripheral resistance.

Which solution would be the most appropriate initial volume replacement for a patient with severe GI
bleeding?

1. 200 mL of normal saline (NS) per hour for 5 hours

2. A liter of Ringer's lactate (RL) over 15 minutes

3. Two liters of D5W over half an hour

4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour - Correct Answer: 2

Rationale 1: This is not an adequate amount of fluid replacement.

Rationale 2: The patient requires immediate infusion of an adequate amount of fluid. Fluid resuscitation
begins with 500 to 1,000 mL of an isotonic solution.

Rationale 3: This is a hypotonic solution and would not help with fluid resuscitation.

Rationale 4: This is a hypotonic solution and would not help with fluid resuscitation.

Which life-threatening complications would the nurse anticipate developing in the patient being treated
for hypovolemic shock?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fluid volume overload

2. Renal insufficiency

3. Cerebral ischemia

4. Gastric stress ulcer

5. Pulmonary edema - Correct Answer: 2,3

Rationale 1: Fluid volume overload is not an identified complication of hypovolemic shock.

Rationale 2: Renal insufficiency is a serious complication because of the prerenal etiology of
hypovolemia.

The benefits of buying summaries with Stuvia:

Guaranteed quality through customer reviews

Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.

Quick and easy check-out

You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.

Focus on what matters

Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!

Frequently asked questions

What do I get when I buy this document?

You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.

Satisfaction guarantee: how does it work?

Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.

Who am I buying these notes from?

Stuvia is a marketplace, so you are not buying this document from us, but from seller otebamanyuru. Stuvia facilitates payment to the seller.

Will I be stuck with a subscription?

No, you only buy these notes for CA$20.92. You're not tied to anything after your purchase.

Can Stuvia be trusted?

4.6 stars on Google & Trustpilot (+1000 reviews)

62890 documents were sold in the last 30 days

Founded in 2010, the go-to place to buy study notes for 14 years now

Start selling