Nokea
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.
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The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
- A. Serum thyroid level findings
- B. Arterial blood gas (ABG) findings
- C. Red blood cells (RBCs) and hemoglobin count findings
- D. White blood cell count findings
Correct Answer: B
Rationale: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid level findings do not help determine the presence of hypoxemia or metabolic acidosis.
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.
The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome would be the best evidence of an improvement in client condition?
- A. A rise in blood count
- B. Alertness in level of consciousness
- C. Increased heart rate
- D. Pulse oxygenation level of $92 \%$
Correct Answer: B
Rationale: In hypovolemic shock, the volume of extracellular fluid is significantly diminished because of lost or reduced blood or plasma. Circulation is impaired. Alertness in the level of consciousness indicates improved circulation and thus oxygenation to the brain. A documented rise in blood count is promising unless tissue damage has already occurred. A decrease in heart rate would mean the heart is no longer struggling to circulate blood to meet tissue needs. A pulse oxygenation level of $92 \%$ is a good sign of available oxygen for the tissue.
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.
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.