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
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.
Question 2 of 5
A client with severe sepsis has a serum lactate level of 6.2 mmol/L. What is the priority nursing action?
Correct Answer: B
Rationale: A serum lactate level of 6.2 mmol/L indicates severe sepsis with tissue hypoperfusion, requiring immediate notification of the health care provider to initiate aggressive treatment, such as fluids, antibiotics, or vasopressors. Oxygen, increased fluids, or insulin may be needed but are not the priority without provider orders.
Question 3 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 4 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 5 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.