Nokea
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, 'What causes the body to go into shock?' Given the client's condition, which statement is most correct?
- A. The client is in shock because the blood volume has decreased in the system.'
- B. The client is in shock because the heart is unable to circulate the body fluids.'
- C. The client is in shock because your loved one is not responding and brain dead.'
- D. The client is in shock because all peripheral blood vessels have massively dilated.'
Correct Answer: A
Rationale: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.
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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 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.
The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock?
- A. Hypervolemic
- B. Distributive
- C. Restrictive
- D. Cardiotonic
Correct Answer: B
Rationale: The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. Distributive, restrictive, and cardiotonic are not categories of shock.
The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?
- A. 1:01
- B. 2:01
- C. 3:01
- D. 4:01
Correct Answer: C
Rationale: Usually, a ratio of $3 \mathrm{~L}$ of fluid is administered for every $1 \mathrm{~L}$ of fluid lost.
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.