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 nurse assesses a client in the emergency department. Unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP?
Correct Answer: B
Rationale: Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness. Reassuring the client is a therapeutic nursing action but not the priority in this situation.
Question 2 of 5
A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?
Correct Answer: A
Rationale: High glucose readings are common in shock due to stress-induced hyperglycemia, and treating them helps maintain blood glucose within a normal range. The other options are incorrect: high glucose in this context is not necessarily diabetic ketoacidosis, IV solutions may contribute but are not the primary cause, and the stress does not cause diabetes.
Question 3 of 5
A nurse caring for a client notes the following assessments: white blood cell count 3800/mm³, temperature 96.8°F, and weak pedal pulses. What action by the nurse takes priority?
Correct Answer: C
Rationale: This client has several indicators of sepsis with systemic inflammatory response, such as low white blood cell count, hypothermia, and poor perfusion (weak pulses). The nurse should notify the health care provider immediately to initiate prompt treatment. Documentation and comfort measures are important but not the priority. Insulin may not be needed in this scenario.
Question 4 of 5
A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?
Correct Answer: B
Rationale: Preventing dehydration in older adults is critical because the age-related decrease in the thirst mechanism makes them prone to dehydration, a risk factor for shock. Drinking fluids on a regular schedule helps maintain hydration. The other options are relevant but less specific to preventing dehydration-related shock.
Question 5 of 5
A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg and is bleeding profusely. What action by the nurse takes priority?
Correct Answer: B
Rationale: Airway is the priority in emergency care, followed by breathing and circulation (IVs and direct pressure). Ensuring a patent airway is critical before addressing bleeding or other interventions. Obtaining consent is typically done by the physician.