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A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first?
- A. Apply personal protective equipment.
- B. Notify local law enforcement officials.
- C. Obtain universal donor blood.
- D. Prepare the client for emergency surgery.
Correct Answer: A
Rationale: The nurse's priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (e.g., gloves) prior to care to ensure safety. This takes priority over notifying law enforcement or preparing for surgery. Requesting blood can be delegated.
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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.
A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)?
- A. It causes vasoconstriction and increased MAP.
- B. Lower blood volume lowers MAP.
- C. There is no direct correlation to MAP.
- D. It raises cardiac output and MAP.
Correct Answer: B
Rationale: Lower blood volume will decrease MAP because reduced blood volume leads to decreased cardiac output and subsequently lower pressure in the arterial system. The other answers are not accurate as they do not correctly describe the physiological response to blood loss.
A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene?
- A. Assessing the IV site before giving the drug.
- B. Obtaining a pump compatible with the IV site.
- C. Removing the IV bag from the brown plastic cover.
- D. Taking and recording a baseline set of vital signs.
Correct Answer: C
Rationale: Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct and appropriate.
A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?
- A. High glucose is common in shock and needs to be treated.
- B. High glucose is a sign of diabetic ketoacidosis.
- C. The IV solution has lots of glucose, which raises blood sugar.
- D. The stress of this illness has made your spouse a diabetic.
Correct Answer: A
Rationale: High glucose readings are common in shock due to stress-induced hyperglycemia, and treating them helps maintain blood glucose within a normal range. The other options are incorrect: high glucose in this context is not necessarily diabetic ketoacidosis, IV solutions may contribute but are not the primary cause, and the stress does not cause diabetes.
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.