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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.
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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 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 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 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 client with severe sepsis has a serum lactate level of 6.2 mmol/L. What is the priority nursing action?
- A. Administer oxygen via nasal cannula.
- B. Notify the health care provider immediately.
- C. Increase the IV fluid infusion rate.
- D. Administer insulin per sliding scale.
Correct Answer: B
Rationale: A serum lactate level of 6.2 mmol/L indicates severe sepsis with tissue hypoperfusion, requiring immediate notification of the health care provider to initiate aggressive treatment, such as fluids, antibiotics, or vasopressors. Oxygen, increased fluids, or insulin may be needed but are not the priority without provider orders.