Nokea
The nurse is performing hourly assessments on a client in the compensation stage of shock. In documenting the hourly urine output of $40 \mathrm{~mL}$ from the Foley catheter, which nursing action is most appropriate?
- A. Reposition the client and make sure there are no kinks in the catheter tubing.
- B. Notify the physician of the hourly output and encourage physician assessment.
- C. Record $40 \mathrm{~mL}$ as the hourly output.
- D. Notify the family of the urine output.
Correct Answer: C
Rationale: Urine output above $35 \mathrm{~mL} /$ hour or $500 \mathrm{~mL} /$ day indicates adequate kidney perfusion. The hourly output would be documented in the client record. There is no need to reposition the client or look for a kink because adequate amounts of urine is collecting in the tube. There is no need to notify the physician or family.
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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 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 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 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 assessing a 6-year-old child in the emergency department (ED) who was brought in by the parent. The child was stung by a bee and is allergic to bee venom. The child is now having trouble breathing, and is vasodilated, hypotensive, and has broken out in hives. What does the nurse suspect is wrong with this child?
- A. The child is having an allergic reaction and going into cardiogenic shock.
- B. The child is having an allergic reaction and going into anaphylactic shock.
- C. The child is having an allergic reaction and going into neurogenic shock.
- D. The child is having an allergic reaction and going into obstructive shock.
Correct Answer: B
Rationale: Anaphylactic shock is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive (see Ch. 34). Common allergic substances include bee venom, latex, fish, nuts, and penicillin. The body's immune response to the allergic substance causes mast cells in the connective tissues, bronchi, and gastrointestinal tract to release histamine and other chemicals. The results are vasodilatation, increased capillary permeability accompanied by swelling of the airway and subcutaneous tissues, hypotension, and hives or an itchy rash. Cardiogenic shock, neurogenic shock, and obstructive shock would not begin with vasodilation, swelling of the airway, and hives.