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 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.
Question 2 of 5
A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first?
Correct Answer: A
Rationale: The nurse's priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (e.g., gloves) prior to care to ensure safety. This takes priority over notifying law enforcement or preparing for surgery. Requesting blood can be delegated.
Question 3 of 5
A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider?
Correct Answer: B
Rationale: A creatinine level of 6 mg/dL is significantly elevated, indicating potential renal dysfunction, which is a critical concern in clients at risk for shock. The nurse should notify the health care provider immediately. The other values are within or near normal ranges.
Question 4 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 5 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.