Shock NCLEX style questions

Shock NCLEX style questions Leave the first rating Terms in this set (11) Science MedicineNursing Save The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?16 The pulse pressure is the systolic BP minus the diastolic BP.

100-60 = 40

88-64 = 24

40-24= 16 Pulse pressure narrowing A narrowing or decreased pulse pressure is an earlier indicator of shock than a decrease in systolic BP

The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?

• Start an IV with an 18 gauge

catheter

• Administer dopamine intravenous

infusion

• Obtain ABGs
• Insert an indwelling urinary

catheter

• There are many types of shock but the one

common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?

• Vital signs T 100.4 f P 104 R 26 BP

102/60

• White blood count of 18,000
• A urinary output of 90 mL in the

last 4 hours

• The client complains of thrist
• The client must have a urinary output of atleast

30 mL/hr, so 90 mL in the last 4 hours indicates imparied renal perfusion, which is a sign of worsening shock and warrants immediate intervention The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority?

• Provide clear liquid diet
• Initiate IV antibiotic therapy
• Obtain STAT chest x-ray
• Perform hourly glucose check
• IV antibiotic is the priority medication for a client

with an infection, which is the definition of sepsis- a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one hour of receiving the order.

The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?

• Cool moist skin
• Bradycardia
• Wheezing
• Decreased Bowel sounds
• The client will have bradycardia instead of

tachycardia, which is seen in other forms of shock The nurse in the ED administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement?

• Ask the client about drug allergies
• Obtain a sterile sputum specimen
• Have the client wait 30 minutes
• Place a warm washcloth on the

client's left hip

• Anytime a nurse administers a medication for the

first time, the client should be observed for possible anaphylactic reaction, especially antibiotics The nurse caring for a client with sepsis writes the client a diagnosis of "alteration in comfort R/T chills and fever" Which intervention should be included in the plan of care?

• Ambulate the client in the hallway

every shift

• Monitor urinalysis, creatinine level,

and BUN level

• Apply sequential compression

devices to the lower extremities

• Administer an antipyretic

medication every 4 hours PRN

• Antipyretic medication will help decrease the

client's fever, which directly address the etiology of the client's nursing diagnosis.

An elderly female client with vertebral fractures who has been self-medicating with ibuprofen a NSAID presents to the ED complaining of abdominal pain, is pale and clammy, and has a pulse of 110 and a BP of 92/60. Which type of shock should the nurse suspect?

• Cardiogenic shock
• Hypovolemic shock
• Neurogenic shock
• Septic shock
• These client's signs/symptoms make the nurse

suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging The client has recently experienced a myocardial infarction. Which action by he nurse helps prevent cardiogenic shock?

• Monitor the client's telemetry
• Turn the client every 2 hours
• Administer oxygen via nasal

cannula

• Place the client in trendlenburg

position

• Promoting adequate oxygenation of the heart

muscle and decreasing the cardiac workload can prevent cardiogenic shock