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 nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock?
Correct Answer: B
Rationale: The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. Distributive, restrictive, and cardiotonic are not categories of shock.
Question 2 of 5
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?
Correct Answer: C
Rationale: Adrenergic drugs are the main medications used to treat shock due to their action on the receptors of the sympathetic nervous system.
Question 3 of 5
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?
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.
Question 4 of 5
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?
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.
Question 5 of 5
The nurse is caring for a client with shock accompanied by lung congestion. How would the nurse position this client?
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.