Nokea
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.
You may also like to solve these questions
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.
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 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 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.
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.