Nokea
The nurse is caring for a client who does not accept blood or blood products. Which nursing action(s) conserves blood? Select all that apply.
- A. Administer medication to stimulate bone marrow.
- B. Draw minimum volume of blood for diagnostic tests.
- C. Administer plasma to expand intravascular volume.
- D. Reinfuse the client's own blood via closed circuit container.
- E. Administer factor VIII to stimulate coagulation process.
- F. Administer blood product only in an emergency.
Correct Answer: A,B,D,E
Rationale: The client that does not accept blood or blood products will accept medications to stimulate the natural production of cells or cause the current cells to last. Also measures that use the blood product wisely are stressed. Plasma is a component of the blood so the client would not permit the infusion and will not consent to blood products in an emergency.
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The nurse is performing hourly assessments on a client in the compensation stage of shock. In documenting the hourly urine output of $40 \mathrm{~mL}$ from the Foley catheter, which nursing action is most appropriate?
- A. Reposition the client and make sure there are no kinks in the catheter tubing.
- B. Notify the physician of the hourly output and encourage physician assessment.
- C. Record $40 \mathrm{~mL}$ as the hourly output.
- D. Notify the family of the urine output.
Correct Answer: C
Rationale: Urine output above $35 \mathrm{~mL} /$ hour or $500 \mathrm{~mL} /$ day indicates adequate kidney perfusion. The hourly output would be documented in the client record. There is no need to reposition the client or look for a kink because adequate amounts of urine is collecting in the tube. There is no need to notify the physician or family.
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?
- A. Limit interaction with visitors.
- B. Avoid heavy meals.
- C. Maintain activity restriction to bedrest.
- D. Arrange personal care supplies nearby.
Correct Answer: C
Rationale: Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.
The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessment(s) that signal early signs of the decompensation stage? Select all that apply.
- A. Vital signs
- B. Nutrition
- C. Skin color
- D. Gait
- E. Urine output
- F. Peripheral pulses
Correct Answer: A,C,E,F
Rationale: Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation.
The nurse is caring for an older adult client receiving dopamine therapy for the treatment of shock. For which complication should the nurse monitor?
- A. Hypoglycemia
- B. Water intoxication
- C. Photophobia
- D. Rapid increase in blood pressure
Correct Answer: D
Rationale: The nurse should monitor an older adult client receiving dopamine therapy for the treatment of shock for a rapid increase in blood pressure. Hyperglycemia, not hypoglycemia, is a potential complication of dopamine therapy. Water intoxication is a potential complication of vasopressin. Photophobia is a potential complication of sympathomimetic vasopressor agents.
A nurse educator is teaching students the types of shock and associated causes. Which combination(s) of shock type and causative factors is correct? Select all that apply.
- A. Hypovolemic shock; blood loss
- B. Obstructive shock; kidney stone
- C. Cardiogenic shock; myocardial infarction
- D. Anaphylactic shock; nut allergy
- E. Septic shock; infection
- F. Neurogenic shock; diabetes
Correct Answer: A,C,D,E
Rationale: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interference in blood flow through the heart. Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.