Nokea
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.
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The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?
- A. Decreased white blood cell count
- B. Increase in arterial oxygenation
- C. Decreased depressive symptoms
- D. Regulation of sodium and potassium
Correct Answer: B
Rationale: Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. Catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation, improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.
The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?
- A. Slow the heart rate
- B. Increase the force of myocardial contraction
- C. Depress the central nervous system
- D. Dilate the bronchial tree
Correct Answer: B
Rationale: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.
The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?
- A. Central venous pressure reflects the pressure in the right atrium or venae cavae.'
- B. A pulmonary artery pressure provides information about pressure on the left side of the heart.'
- C. The trend in central venous pressure is more helpful than isolated readings.'
- D. Pulmonary artery pressure and pulmonary capillary pressure is assessed by an inserted catheter.'
Correct Answer: B
Rationale: The most pertinent information to share with a new nurse is the information that the pulmonary artery pressure provides essential information about the effectiveness of left ventricle. The left ventricle is most pertinent to circulation. The other information is correct but not as pertinent.
The nurse is caring for a client in the compensation stage of shock. The nurse knows that one of the body's mechanisms of compensation in this stage of shock is the renin- angiotensin-aldosterone system. What does this system do?
- A. Decreases peripheral blood flow
- B. Increases catecholamine secretion
- C. Increases the production of antidiuretic hormone
- D. Restores blood pressure
Correct Answer: D
Rationale: The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone.
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.