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 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.
Question 2 of 5
The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: Immobility, decreased thirst response, diminished immune response, and malnutrition increase the risk of shock in older adults due to their impact on circulation, hydration, infection susceptibility, and overall resilience. Overhydration is not a common risk factor for shock.
Question 3 of 5
A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.)
Correct Answer: A,D,E
Rationale: The nurse can delegate bringing warm blankets, reorienting the client to decrease anxiety, and sitting with the client for reassurance. Providing hot tea is inappropriate as the client should be NPO. Massaging the legs is not recommended due to the risk of dislodging clots, which could lead to pulmonary embolism.
Question 4 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 5 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.