ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 37 : Care of Patients with Shock Questions
Question 1 of 5
A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?
Correct Answer: B
Rationale: Lack of access to clean water (implied by the hope to get water turned back on) increases the risk of infection due to poor hygiene, especially with an unhealed wound. This poses a higher risk for sepsis compared to social gatherings, exposure to litter boxes, or family excitement.
Question 2 of 5
The nurse is planning care for a client at risk for shock. What interventions are most critical to preventing shock? (Select all that apply.)
Correct Answer: A,C,D,E
Rationale: Assessing and identifying clients at risk for shock is critical to prevent its occurrence. Proper hand hygiene, using aseptic technique, and removing invasive lines reduce infection risk, a common cause of shock. Monitoring white blood cell count is useful for detecting changes but does not prevent shock.
Question 3 of 5
The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: Immobility, decreased thirst response, diminished immune response, and malnutrition increase the risk of shock in older adults due to their impact on circulation, hydration, infection susceptibility, and overall resilience. Overhydration is not a common risk factor for shock.
Question 4 of 5
A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.)
Correct Answer: A,D,E
Rationale: The nurse can delegate bringing warm blankets, reorienting the client to decrease anxiety, and sitting with the client for reassurance. Providing hot tea is inappropriate as the client should be NPO. Massaging the legs is not recommended due to the risk of dislodging clots, which could lead to pulmonary embolism.
Question 5 of 5
The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.)
Correct Answer: A,B,D
Rationale: Within the first 3 hours of suspecting severe sepsis, the nurse should facilitate obtaining blood cultures, drawing serum lactate levels, and administering antibiotics (after cultures). Infusing vasopressors and measuring central venous pressure are typically performed within 6 hours.