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NUR200 – Shock: Questions & Answers (100% Correct)
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NUR200 – Shock: Questions & Answers (100% Correct)
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NUR200 – Shock: Questions & Answers (100% Correct)Which vital sign change in a client with hypovolemic shock indicates to the
nurse that the therapy is effective?
A. Urine output increase from 5mL/hr to 25mL/hr
B. Pulse pressure decrease from 35 mm Hg to 28 mm Hg
C. Respiratory rate increase from 22 breaths/min to 28 breaths/min
D. Core body temperature increase from 98.2F (36.8C) to 98.8F (37.1C)
Right Ans - A. Urine output increase from 5mL/hr to 25mL/hr
(During shock, the kidneys and baroreceptors sense an ongoing decrease in
MAP and trigger the release of renin, antidiuretic hormone (ADH),
aldosterone, epinephrine, and norepinephrine to start kidney compensation,
which is very sensitive to changes in fluid volume. Renin, secreted by the
kidney, causes decreased urine output. ADH increases water reabsorption in
the kidney, further reducing urine output. These actions compensate for shock
by attempting to prevent further fluid loss. This response is so sensitive that
urine output is a very good indicator of fluid resuscitation adequacy. If the
therapy is not effective, urine output does not increase.
Reference: p. 819, Safe and Effective Care Environment)
Which newly admitted client does the nurse consider to be at highest risk for
development of sepsis?
A. 75 y/o man with hypertension and early Alzheimer's disease.
B. 68 y/o woman 2 days postoperative from bowel surgery
C. 80 y/o community-dwelling man with no other health problems undergoing
cataract surgery
D. 54 y/o woman with moderate asthma and severe degenerative joint
disease of the right knee Right Ans - B. 68 y/o woman 2 days postoperative
from bowel surgery
(The 68-year-old woman has several risk factors. First she is an older adult,
and immune function decreases with age. The greatest risk factor is that she
has just had bowel surgery. Not only does major surgery further reduce the
immune response, the bowel cannot be "sterilized" for surgery. Therefore the
usual bacteria of the bowel have the chance to escape the site and enter the
bloodstream when the bowel is disrupted.
Reference: p. 822, Safe and Effective Care Environment)
, The nurse is caring for postoperative clients at risk for hypovolemic shock.
Which of these represents early symptoms of shock?
A. Hypotension
B. Bradypnea
C. Heart blocks
D. Tachycardia Right Ans - D. Tachycardia
(Heart and respiratory rates increased from the client's baseline level or a
slight increase in diastolic blood pressure may be the only objective
manifestation of this early stage of shock.)
Which of the these problems in the clients below best demonstrates highest
risk for hypovolemic shock?
A. Client receiving a blood transfusion
B. Client with severe ascites
C. Client with myocardial infarction
D. Client with syndrome of inappropriate antipyretic hormone (ADH)
secretion (SIADH) Right Ans - B. Client with severe ascites
(Fluid shifts from vascular to intra-abdominal may cause decreased
circulating blood volume and poor tissue perfusion.)
The nurse is caring for a client in the refractory stage of cardiogenic shock.
Which intervention should the nurse consider?
A. Admission to rehab hospital for ambulatory retraining
B. Collaboration with home care agency for return to home.
C. Discussion with family and provider regarding palliative care.
D. Enrollment in a cardiac transplantation program. Right Ans - C.
Discussion with family and provider regarding palliative care.
(In this irreversible phase, therapy is not effective in saving the client's life,
even if the cause of shock is corrected and mean MAP temporarily returns to
normal. A discussion on palliative care should be considered.)
Situation: A client with septic shock has been started on dopamine (Intropin)
at 12 mcg/kg/min. Which response indicates a positive outcome?
A. Hourly urine output 10 to 12 mL/hr
B. B/P 90/60 and MAP 70
C. Blood glucose 245
D. Serum creatinine 3.6 mg/dl Right Ans - B. B/P 90/60 and MAP 70
(Dopamine improves blood flow by increasing peripheral resistance, which
increases blood pressure - a positive response.)
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