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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.
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A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?
- A. All my friends and neighbors are planning a party for me.
- B. I hope I can get my water turned back on when I get home.
- C. My neighbor has several cats with litter boxes in the home.
- D. My grandkids are so excited to have me coming home.
Correct Answer: B
Rationale: Lack of access to clean water (implied by the hope to get water turned back on) increases the risk of infection due to poor hygiene, especially with an unhealed wound. This poses a higher risk for sepsis compared to social gatherings, exposure to litter boxes, or family excitement.
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.
A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last checked 3 hours ago. What action by the nurse is best?
- A. Ask if the client needs pain medication.
- B. Assess the client's tissue perfusion further.
- C. Document the findings in the client's chart.
- D. Increase the rate of the client's IV infusion.
Correct Answer: B
Rationale: Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, and blood pressure. Although these readings are not out of the normal range, the nurse should perform a thorough assessment of the client, focusing on indicators of perfusion to detect early shock. Pain medication and documentation are important but not the priority. Increasing IV infusion rate requires a medical order and is not the first action.
A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
- A. Alert and oriented, answering questions.
- B. Client denial of chest pain or chest pressure.
- C. IV site without redness or swelling.
- D. Urine output of 30 mL/hr for 2 hours.
Correct Answer: A
Rationale: Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine, which improves perfusion to vital organs, including the brain. Absence of chest pain, normal IV site, and minimal urine output do not specifically indicate the therapeutic effect of norepinephrine.
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.