Nokea
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.
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The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body?
- A. Activation of renin-angiotensin-aldosterone system
- B. Secretion of epinephrine and norepinephrine
- C. Production of antidiuretic hormone and corticosteroid hormones
- D. Release of catecholamines
Correct Answer: C
Rationale: Antidiuretic hormone (ADH) and corticosteroid hormones play an active role in controlling sodium and water balance. Both ADH and corticosteroid hormones promote fluid reabsorption and retention. The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. The release of catecholamines stimulates secretion of epinephrine and norepinephrine.
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 obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following?
- A. The difference between an apical and radial pulse
- B. The difference between an upper extremity and lower extremity blood pressure
- C. The difference between the systolic and diastolic pressure
- D. The difference between the arterial and venous blood pressure
Correct Answer: C
Rationale: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.
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.
The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, $97.2^{\circ} \mathrm{F}$; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, $102 / 78 \mathrm{~mm} \mathrm{Hg}$; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?
- A. Within normal limits
- B. Thready
- C. 24
- D. Palpable
Correct Answer: C
Rationale: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24 . The pulse pressure does not report quality of the pulse.