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 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 2 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 3 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.
Question 4 of 5
A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
Correct Answer: A
Rationale: Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine, which improves perfusion to vital organs, including the brain. Absence of chest pain, normal IV site, and minimal urine output do not specifically indicate the therapeutic effect of norepinephrine.
Question 5 of 5
A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene?
Correct Answer: C
Rationale: Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct and appropriate.