Nclex Questions for Shock - Critical Care

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.

• Temperature of 97.6°F (36.4°C)
• Restlessness
• Decrease in blood pressure of 20 mm Hg when the patient sits up
• 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?

• Serum sodium of 130 mEq/L (130 mmol/L)
• Metabolic acidosis validated by arterial blood gases
• 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. 1 / 3

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:

• Decreased cardiac output
• Severe constipation, causing watery diarrhea
• 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?

• Strong bounding pulse with deep red coloring
• Pale, cool extremities with decreased pulses
• 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. 2 / 3

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?

• 200 mL of normal saline (NS) per hour for 5 hours
• A liter of Ringer's lactate (RL) over 15 minutes
• Two liters of D5W over half an hour
• 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.

• Fluid volume overload
• Renal insufficiency
• Cerebral ischemia
• 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.

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