ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 17 : Caring for Clients in Shock Questions
Question 1 of 5
The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome would be the best evidence of an improvement in client condition?
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.
Question 2 of 5
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?
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.
Question 3 of 5
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?
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.
Question 4 of 5
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?
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.
Question 5 of 5
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?
Correct Answer: B
Rationale: The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.