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ATI CARDIAC ( UPDATED 2024 ) COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
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ATI CARDIAC ( UPDATED 2024 ) COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
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ATI CARDIAC ( UPDATED 2024 )COMPLETE QUESTIONS & ANSWERS (SOLVED) 100%
CORRECT
1. A client is receiving norepinephrine (Levophed) for shock. What assessment finding best
indicates a therapeutic effect from this drug?
a. Alert and 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: a. Alert and oriented, answering questions
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 outputis normal, but only
minimally so.
2. A nurse is caring for several clients at risk for shock. Which laboratoryvalue requires the
nurse to communicate with the health care provider?
a. Creatinine: 0.9 mg/dL
b. Lactate: 6 mmol/L
c. Sodium: 150 mEq/L
d. White blood cell count: 11,000/mm3: b. Lactate: 6 mmol/L
A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of
0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to
shock. A white blood cell count of 11,000/mm3 is slightly high butis not as critical as the
lactate level.
3. A client in shock is apprehensive and slightly confused.What action by thenurse is best?
a. Offer to remain with the client for awhile.
b. Prepare to administer antianxiety medication.
c. Raise all four siderails on the clients bed.
d. Tell the client everything possible is being done.: a. Offer to remain with theclient for
awhile.
The nurses presence will be best to reassure this client. Antianxiety medication is not
warranted as this will lower the clients blood pressure. Using all four siderails ona hospital bed
is considered a restraint in most facilities, although the nurse shouldensure the clients safety.
,Telling a confused client that everything is being done is not the most helpful response.
4. A client in shock has been started on dopamine. What assessment findingrequires the nurse
to communicate with the 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
Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine.
While taking dopamine, the oxygen requirements of the heart are increased due to increased
myocardial workload, and may cause ischemia. Withoutknowing the clients previous blood
pressure or pedal pulses, there is not enough information to determine if these are an
improvement or not. A urine output of 32 mL/hr is acceptable.
5. The student nurse studying shock understands that the common manifestations of this
condition are directly related to which problems? (Select all thatapply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased perfusion: a. Anaerobic metabolism
c. Hypotension
The common manifestations of shock, no matter the cause, are directly related to theeffects of
anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and
increased perfusion are not manifestations of shock.
6. The nurse caring for hospitalized clients includes which actions on their care plans to
reduce the possibility of the clients developing shock? (Selectall 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 identifyingclients at risk
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
, Assessing and identifying clients at risk for shock is probably the most critical actionthe nurse
can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and
removing IV lines and catheters are also important actions toprevent shock. Monitoring
laboratory values does not prevent shock but can indicatea change.
7. 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 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: a. Altered mobility/immobility
b. Decreased thirst response
c. Diminished immune response
d. Malnutrition
Immobility, decreased thirst response, diminished immune response, and malnutri-tion can
place the older adult at higher risk of developing shock. Overhydration is not a common risk
factor for shock.
8. A client is in the early stages of shock and is restless. What comfort measures does the
nurse delegate to the nursing student? (Select all thatapply.)
a. Bringing the client warm blankets
b. Giving the client hot tea to drink
c. Massaging the clients painful legs
d. Reorienting the client as needed
e. Sitting with the client for reassurance: a. Bringing the client warm blankets
d. Reorienting the client as needed
e. Sitting with the client for reassurance
The student can bring the client warm blankets, reorient the client as needed to decrease
anxiety, and sit with the client for reassurance. The client should be NPOat this point, so hot
tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots
present, which may lead to pulmonary embolism.
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