Nokea
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
- A. A rapid, bounding pulse
- B. A slow but steady pulse
- C. A weak and thready pulse
- D. A slow and imperceptible pulse
Correct Answer: A
Rationale: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.
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The nurse is caring for the client with massive blood loss from a gunshot wound, and type-specific blood is currently not available for transfusion. With little time to spare, which blood type does the nurse infuse?
- A. Type A+
- B. Type B+
- C. Type A/B-
- D. Type O-
Correct Answer: D
Rationale: When type-specific blood is not available and a transfusion is required, type $\mathrm{O}-$ blood is infused. Type A+, B+, and Type A/B- are not infused when type-specific blood is not available.
The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following?
- A. The difference between an apical and radial pulse
- B. The difference between an upper extremity and lower extremity blood pressure
- C. The difference between the systolic and diastolic pressure
- D. The difference between the arterial and venous blood pressure
Correct Answer: C
Rationale: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.
The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?
- A. Blanch the nailbeds.
- B. Inspect the conjunctiva.
- C. Note dullness in skin color.
- D. Assess the earlobe.
Correct Answer: B
Rationale: In clients with highly pigmented skin, cyanosis is more accurately detected by inspecting the conjunctiva and oral mucous membranes. The other options do not provide the best assessment for cyanosis.
A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?
- A. Anaphylactic
- B. Neurogenic
- C. Septic
- D. Obstructive
Correct Answer: B
Rationale: Neurogenic shock results from an insult to the vasomotor center of the medulla or to the peripheral nerves that extend from the spinal cord to the blood vessels. The tone of the sympathetic nervous system is impaired, resulting in deceased arterial vascular resistance, vasodilation, and hypotension. Anaphylactic shock has vasodilation also as a key characteristic, along with increased capillary permeability, swelling of the airway, hives, and itching. Septic shock is associated with overwhelming bacterial infections. Obstructive shock is when there is an interference of blood flow in and out of the heart.
A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?
- A. Liver dysfunction
- B. Organ damage
- C. Weight loss
- D. Unsteady gait
Correct Answer: B
Rationale: When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.