Nokea
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.
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The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?
- A. Place a cool compress on head.
- B. Elevate the legs higher than the heart.
- C. Shake the client to arouse.
- D. Cover the client with a blanket.
Correct Answer: B
Rationale: The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.
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 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 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.
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.