NCLEX questions on Shock

NCLEX questions on Shock 10 studiers in 3 days 4.7 (22 reviews) Terms in this set (25) Forsyth Technical Community College NUR 213 Save

• A patient with septic shock has a

urine output of 20 mL/hr for the past

• hours. The pulse

rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low.Which of these orders by the health care provider will the nurse question?

• Give furosemide (Lasix) 40 mg IV.
• Increase normal saline infusion to

150 mL/hr.

• Administer hydrocortisone

(SoluCortef) 100 mg IV.

• Prepare to give drotrecogin alpha

(Xigris) 24 mcg/kg/hr.

ANS: A

Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.DIF: Cognitive Level: Application REF: 1724-1726 |

1731 | 1733

TOP: Nursing Process: Implementation MSC:

NCLEX: Physiological Integrity

• A patient with shock of unknown

etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question?

• Infuse normal saline at 250 mL/hr.
• Keep head of bed elevated to 30

degrees.

• Give nitroprusside (Nipride) unless

systolic BP <90 mm Hg.

• Administer dobutamine (Dobutrex)

to keep systolic BP >90 mm Hg.

ANS: A

The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.DIF: Cognitive Level: Application REF: 1719 | 1721-

1722 | 1735

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

• A patient with massive trauma and

possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?

• Cool, clammy skin
• Inspiratory crackles
• Apical heart rate 48 beats/min
• Temperature 101.2° F (38.4° C)

ANS: C

Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.DIF: Cognitive Level: Comprehension REF: 1721-1722

| 1723

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

• A patient with cardiogenic shock is

cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking?

• Increase the rate for the

prescribed dopamine (Intropin) infusion.

• Decrease the rate for the

prescribed nitroglycerin (Tridil) infusion.

• Decrease the rate for the

prescribed 5% dextrose in water (D5W) infusion.

• Increase the rate for the

prescribed sodium nitroprusside (Nipride) infusion.

ANS: D

Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR.DIF: Cognitive Level: Application REF: 1733-1734 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

• After receiving 1000 mL of normal

saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg.The nurse will anticipate the administration of

• nitroglycerine (Tridil).
• drotrecogin alpha (Xigris).
• norepinephrine (Levophed).
• sodium nitroprusside (Nipride).

ANS: C

When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR.DIF: Cognitive Level: Application REF: 1731 | 1733- 1735 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

• To evaluate the effectiveness of

the omeprazole (Prilosec) being administered to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse make?

• Auscultate bowel sounds.
• Ask the patient about nausea.
• Monitor stools for occult blood.
• Check for abdominal distention.

ANS: C

Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the omeprazole administration.DIF: Cognitive Level: Application REF: 1735-1737 |

1742-1743

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity