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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.
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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.
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 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 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.