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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.
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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.
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.
The nurse is planning care for a client at risk for shock. What interventions are most critical to preventing shock? (Select all that apply.)
- A. Assessing and identifying clients at risk.
- B. Monitoring the daily white blood cell count.
- C. Performing proper hand hygiene.
- D. Removing invasive lines as soon as possible.
- E. Using aseptic technique during procedures.
Correct Answer: A,C,D,E
Rationale: Assessing and identifying clients at risk for shock is critical to prevent its occurrence. Proper hand hygiene, using aseptic technique, and removing invasive lines reduce infection risk, a common cause of shock. Monitoring white blood cell count is useful for detecting changes but does not prevent shock.
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.
A nurse caring for a client notes the following assessments: white blood cell count 3800/mm³, temperature 96.8°F, and weak pedal pulses. What action by the nurse takes priority?
- A. Document the findings in the client's chart.
- B. Give the client warmed blankets for comfort.
- C. Notify the health care provider immediately.
- D. Prepare to administer insulin per sliding scale.
Correct Answer: C
Rationale: This client has several indicators of sepsis with systemic inflammatory response, such as low white blood cell count, hypothermia, and poor perfusion (weak pulses). The nurse should notify the health care provider immediately to initiate prompt treatment. Documentation and comfort measures are important but not the priority. Insulin may not be needed in this scenario.