Nokea
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.
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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 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.
The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.)
- A. Administer antibiotics.
- B. Draw serum lactate levels.
- C. Infuse vasopressors.
- D. Obtain blood cultures.
- E. Measure central venous pressure.
Correct Answer: A,B,D
Rationale: Within the first 3 hours of suspecting severe sepsis, the nurse should facilitate obtaining blood cultures, drawing serum lactate levels, and administering antibiotics (after cultures). Infusing vasopressors and measuring central venous pressure are typically performed within 6 hours.
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 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.