Question 1

A client recovering from septic shock is preparing for discharge home.What priority information does the nurse include in the teaching plan for this client?

Accepted Answer

The client at risk for septic shock should be instructed to clean his or her toothbrush daily,either by running it through the dishwasher or by rinsing it in laundry bleach.Clients should be instructed to bathe daily and wash the armpits,the groin,and the rectal area.The client should refrain from cleaning pet litter boxes.Clients recovering from septic shock are not at higher risk for bleeding disorders.

Question 2

The nurse is assessing a client who was admitted for treatment of shock.Which manifestation indicates that the client's shock is caused by sepsis?

Accepted Answer

The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock.The distinguishing feature is lack of ability to clot blood,causing the client to bleed from areas of minor trauma and to bleed spontaneously.The other manifestations are associated with all types of shock.

Question 3

The emergency department nurse is triaging clients.Which client does the nurse assess most carefully for hypovolemic shock?

Accepted Answer

Hypovolemic shock can be caused by dehydration.A client who has bulimia is at highest risk for dehydration owing to excessive vomiting.Basketball,smoking,and traveling do not put the client at risk for hypovolemic shock.

Question 4

A client who has septic shock is admitted to the hospital.What priority intervention does the nurse implement first?

Accepted Answer

Blood cultures should be obtained before IV antibiotics are started.If hypotension occurs,fluid resuscitation is used first.CVP monitoring and vasopressor therapy are started if hypotension persists.

Question 5

A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding.Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock?

Accepted Answer

The first manifestations of hypovolemic shock result from compensatory mechanisms.Signs of shock are first evident as changes in cardiovascular function.As shock progresses,changes in skin,respiration,and kidney function progress.The other questions would not identify early stages of shock.

Question 6

The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin)drip.Which manifestation is a desired response to this medication?

Accepted Answer

Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure,thereby improving tissue perfusion and oxygenation.Tachycardia is not a desired response but often occurs as a side effect.

Question 7

The nurse is planning care for a client with late-phase septic shock.All of the following treatments have been prescribed.Which prescription does the nurse question?

Accepted Answer

Therapy during the second (late)phase of septic shock is aimed at enhancing the blood's ability to clot.Enoxaparin would increase the client's risk of bleeding and therefore should not be administered during the last phase of septic shock.Administering clotting factors,plasma,platelets,and other blood products will assist the client's blood to clot.Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.

Question 8

The nurse is administering prescribed sodium nitroprusside (Nipride)intravenously to a client who has shock.Which nursing intervention is a priority when administering this medication?

Accepted Answer

The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes.Higher doses can cause systemic vasodilation and can increase shock.The nurse should monitor the client's pain,urinary output,and extremities,but these assessments do not directly relate to the nitroprusside infusion.

Question 9

The intensive care nurse is educating the spouse of a client who is being treated for shock.The spouse states,"The doctor said she has shock.What is that?" What is the nurse's best response?

Accepted Answer

Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency.Shock represents the "whole-body response," affecting all organs in a predictable sequence.Compensation mechanisms attempt to maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal of the cause of shock,resulting in death.

Question 10

The nurse is caring for a client who has had an anaphylactic event.Which priority question does the nurse ask to determine whether the client is experiencing distributive shock?

Accepted Answer

Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals.This results in massive blood vessel dilation and increased capillary leak,which manifests as swelling.The other clinical manifestations do not relate to anaphylaxis or distributive shock.

Question 11

The nurse is caring for a client in the hyperdynamic phase of septic shock.Which medication does the nurse expect to be prescribed?

Accepted Answer

During the hyperdynamic phase of septic shock,because of alterations in the clotting cascade,clients begin to form numerous small clots.Heparin is administered to limit clotting and prevent consumption of clotting factors.The other medications would not be prescribed during the hyperdynamic phase of septic shock.

Question 12

A client was admitted 2 days ago with early stages of septic shock.Today the nurse notes that the client's systolic blood pressure,pulse pressure,and cardiac output are decreasing rapidly.Which intervention does the nurse do first?

Accepted Answer

The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output,systolic blood pressure,and pulse pressure.The nurse must initiate drug therapy to maintain blood pressure and cardiac output.Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client's pulse pressure is decreasing rapidly.The family should be updated appropriately.

Question 13

A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement.Which fluid does the nurse prepare to administer?

Accepted Answer

Ringer's lactate is an isotonic solution that acts as a volume expander.Also,the lactate acts as a buffer in the presence of acidosis.The other solutions do not contain any substance that would buffer or correct the client's acidosis.

Question 14

The nurse is caring for multiple clients in the emergency department.The client with which condition is at highest risk for distributive shock?

Accepted Answer

Distributive shock is the type of shock that occurs when blood volume is not lost from the body but is distributed to the interstitial tissues,where it cannot circulate and deliver oxygen.Neurally-induced distributive shock may be caused by pain,anesthesia,stress,spinal cord injury,or head trauma.The other clients are at risk for hypovolemic and cardiogenic shock.

Question 15

The nurse is assessing a client who has hypovolemic shock.Which laboratory value indicates that the client is at risk for acidosis?

Accepted Answer

The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus some cells are metabolizing anaerobically.Such metabolism increases the production of lactic acid,resulting in an increase in hydrogen ion production and acidosis.Other laboratory values associated with acidosis include increased creatinine (impaired renal function)and increased partial pressure of arterial carbon dioxide.Urine specific gravity is not associated with acidosis.

Question 16

The nurse is providing community education for clients at risk for dehydration.One client states,"We are not at risk because we live in a hot and dry climate." What is the nurse's best response?

Accepted Answer

Teach everyone to prevent dehydration by having adequate fluid intake during exercise or when in a hot and dry environment.Insensitive water loss increases in this type of environment.Heat causes vasodilation as well,also contributing to water loss.The other statements are not accurate.

Question 17

The nurse is caring for a client who has hypovolemic shock.After administering oxygen,what is the priority intervention for this client?

Accepted Answer

IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock.A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids.Aminoglycosides and heparin are given to clients with septic shock.

Question 18

The nurse is assessing a client at risk for shock.The client's systolic blood pressure is 20 mm Hg lower than baseline.Which intervention does the nurse perform first?

Accepted Answer

Administration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia.The other interventions should be completed after oxygen is administered.

Question 19

The nurse is assessing clients in the emergency department.Which client is at highest risk for developing septic shock?

Accepted Answer

Certain conditions or treatments that cause immune suppression,such as having cancer and being treated with chemotherapeutic agents,aspirin,and certain antibiotics,can predispose a person to septic shock.The other client situations do not increase the client's risk for septic shock.

Question 20

The nurse is preparing to administer sodium nitroprusside (Nipride)to a client.Which important action related to the administration of this drug does the nurse implement?

Accepted Answer

Sodium nitroprusside (Nipride)must be protected from light to prevent degradation of the drug.It should be delivered via pump.This medication does not have any effect on respiratory rate.Hypertension is a sign of milrinone (Primacor)overdose.

Quiz 39: Care of Patients With Shock