Nokea
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.
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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 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.
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 reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?
- A. Hemoglobin: $14.2 \mathrm{~g} / \mathrm{dL}$
- B. Potassium: $4.8 \mathrm{mEq} / \mathrm{L}$
- C. WBC: $42,000 / \mathrm{mm} 3$
- D. ESR: $19 \mathrm{~mm} /$ hour
Correct Answer: C
Rationale: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.
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.