Nokea
The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
- A. Serum thyroid level findings
- B. Arterial blood gas (ABG) findings
- C. Red blood cells (RBCs) and hemoglobin count findings
- D. White blood cell count findings
Correct Answer: B
Rationale: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid level findings do not help determine the presence of hypoxemia or metabolic acidosis.
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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 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 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.
The nurse is caring for a client with shock accompanied by lung congestion. How would the nurse position this client?
- A. Completely supine
- B. Low Fowler's with legs flat
- C. Supine with lower extremities raised to approximately $45^{\circ}$
- D. Semi-Fowler's with lower extremities raised to approximately $15^{\circ}$
Correct Answer: D
Rationale: For a client with shock accompanied by lung congestion, the nurse should raise the client's upper body to approximately $45^{\circ}$ and lower extremities to approximately $15^{\circ}$. Elevating the upper body lowers the diaphragm and provides more room for lung expansion and gas exchange. Elevating the head reduces intracranial pressure. Elevating the legs promotes blood perfusion to the heart, lungs, and brain.
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.