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 student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)?
Correct Answer: B
Rationale: Lower blood volume will decrease MAP because reduced blood volume leads to decreased cardiac output and subsequently lower pressure in the arterial system. The other answers are not accurate as they do not correctly describe the physiological response to blood loss.
Question 2 of 5
A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last checked 3 hours ago. What action by the nurse is best?
Correct Answer: B
Rationale: Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, and blood pressure. Although these readings are not out of the normal range, the nurse should perform a thorough assessment of the client, focusing on indicators of perfusion to detect early shock. Pain medication and documentation are important but not the priority. Increasing IV infusion rate requires a medical order and is not the first action.
Question 3 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 4 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 5 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.