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A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg and is bleeding profusely. What action by the nurse takes priority?
- A. Apply direct pressure to the bleeding.
- B. Ensure the client has a patent airway.
- C. Obtain consent for emergency surgery.
- D. Start two large-bore IV catheters.
Correct Answer: B
Rationale: Airway is the priority in emergency care, followed by breathing and circulation (IVs and direct pressure). Ensuring a patent airway is critical before addressing bleeding or other interventions. Obtaining consent is typically done by the physician.
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A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider?
- A. Creatinine 0.6 mg/dL.
- B. Creatinine 6 mg/dL.
- C. Hemoglobin 12 g/dL.
- D. Potassium 4.0 mEq/L.
Correct Answer: B
Rationale: A creatinine level of 6 mg/dL is significantly elevated, indicating potential renal dysfunction, which is a critical concern in clients at risk for shock. The nurse should notify the health care provider immediately. The other values are within or near normal ranges.
A nurse assesses a client in the emergency department. Unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP?
- A. Assess the client for pain or discomfort.
- B. Measure urine output from the catheter.
- C. Reposition the client to the unaffected side.
- D. Keep with the client and reassure him or her.
Correct Answer: B
Rationale: Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness. Reassuring the client is a therapeutic nursing action but not the priority in this situation.
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.
Correct Answer: A,B,C,D
Rationale: Immobility, decreased thirst response, diminished immune response, and malnutrition increase the risk of shock in older adults due to their impact on circulation, hydration, infection susceptibility, and overall resilience. Overhydration is not a common risk factor for shock.
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 that apply.)
- A. Bringing the client warm blankets.
- B. Providing the client with hot tea.
- C. Massaging the client's painful legs.
- D. Reorienting the client as needed.
- E. Sitting with the client for reassurance.
Correct Answer: A,D,E
Rationale: The nurse can delegate bringing warm blankets, reorienting the client to decrease anxiety, and sitting with the client for reassurance. Providing hot tea is inappropriate as the client should be NPO. Massaging the legs is not recommended due to the risk of dislodging clots, which could lead to pulmonary embolism.
A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?
- A. Do not get dehydrated in warm weather.
- B. Drink fluids on a regular schedule.
- C. Seek attention for any lacerations.
- D. Take medications as prescribed.
Correct Answer: B
Rationale: Preventing dehydration in older adults is critical because the age-related decrease in the thirst mechanism makes them prone to dehydration, a risk factor for shock. Drinking fluids on a regular schedule helps maintain hydration. The other options are relevant but less specific to preventing dehydration-related shock.