H11

Question 1

A nurse in the ICU is planning the care of a client who is being treated for shock. What
statement best describes the pathophysiology of this client’s health problem?
A. Blood is shunted from vital organs to peripheral areas of the body.
B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
C. Circulating blood volume is decreased with a resulting change in the osmotic
pressure gradient.
D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate
perfusion.

Answer 1

ANS: B
Rationale: Shock is a life-threatening condition with a variety of underlying causes.
Shock is caused when the cells do not have an adequate blood supply and are deprived of
oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the
body to the vital organs. Hemorrhage and decreased blood volume are associated with
some, but not all, types of shock.

Question 2

In an acute care setting, the nurse is assessing an unstable client. When prioritizing
the client’s care, the nurse should recognize that the client is at risk for hypovolemic
shock in which of the following circumstances?
A. Fluid volume circulating in the blood vessels decreases.
B. There is an uncontrolled increase in cardiac output.
C. Blood pressure regulation becomes irregular.
D. The client experiences tachycardia and a bounding pulse.

Answer 2

ANS: A
Rationale: Hypovolemic shock is characterized by a decrease in intravascular volume.
Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.

Question 3

The emergency nurse is admitting a client experiencing a GI bleed who is believed to
be in the compensatory stage of shock. What assessment finding would be most
consistent with the early stage of compensation?
A. Increased urine output
B. Decreased heart rate
C. Hyperactive bowel sounds
D. Cool, clammy skin

Answer 3

ANS: D
Rationale: In the compensatory stage of shock, the body shunts blood from the organs,
such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As
a result, the client’s skin is cool and clammy. Also in this compensatory stage, blood
vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the
urine output decreases.

Question 4

The intensive care nurse caring for a client in shock is planning assessments and
interventions related to the client’s nutritional needs. Which physiologic process
contributes to these increased nutritional needs?
A. The use of albumin as an energy source by the body because of the need for
increased adenosine triphosphate
B. The loss of fluids due to decreased skin integrity and decreased stomach acids
due to increased parasympathetic activity
C. The release of catecholamines that creates an increase in metabolic rate and
caloric requirements
D. The increase in gastrointestinal (GI) peristalsis during shock, and the resulting
diarrhea

Answer 4

ANS: C
Rationale: Nutritional support is an important aspect of care for clients in shock. Clients
in shock may require 3,000 calories daily. This caloric need is directly related to the
release of catecholamines and the resulting increase in metabolic rate and caloric
requirements. Albumin is not primarily metabolized as an energy source. The special
nutritional needs of shock are not related to increased parasympathetic activity, but are
instead related to increased sympathetic activity. GI function does not increase during
shock.

Question 4

A client who is in shock is receiving dopamine in addition to IV fluids. What principle
should inform the nurse’s care planning during the administration of a vasoactive drug?
A. The drug should be discontinued immediately after blood pressure increases.
B. The drug dose should be tapered down once vital signs improve.
C. The client should have arterial blood gases drawn every 10 minutes during
treatment.
D. The infusion rate should be titrated according the client’s subjective sensation of
adequate perfusion.

Answer 4

ANS: B
Rationale: When vasoactive medications are discontinued, they should never be stopped
abruptly because this could cause severe hemodynamic instability, perpetuating the
shock state. Subjective assessment data are secondary to objective data. Arterial blood
gases should be carefully monitored, but draws every 10 minutes are not the norm.

Question 4

The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic
shock following injuries from a motor vehicle accident. In addition to normal saline, which
crystalloid fluid should the nurse prepare to administer?
A. Lactated Ringer
B. Albumin
C. Dextran
D. 3% NaCl

Answer 4

ANS: A
Rationale: Crystalloids are electrolyte solutions used for the treatment of hypovolemic
shock. Lactated Ringer and 0.9% sodium chloride are isotonic crystalloid fluids commonly
used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even
as a colloid, is not indicated for the treatment of hypovolemic shock. The 3% NaCl is a
hypertonic solution and is not isotonic.

Question 5

A nurse in the intensive care unit (ICU) receives a report from the nurse in the
emergency department (ED) about a new client being admitted with a neck injury
received while diving into a lake. The ED nurse reports that the client’s blood pressure is
85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU
nurse recognize that the client is probably experiencing?
A. Anaphylactic shock
B. Neurogenic shock
C. Septic shock
D. Hypovolemic shock

Answer 5

ANS: B
Rationale: Neurogenic shock can be caused by spinal cord injury. The client will present
with a low blood pressure; bradycardia; and warm, dry skin due to the loss of
sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock
is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused
by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents
with tachycardia and a probable source of blood loss.

Question 5

The nurse is transferring a client who is in the progressive stage of shock into the
intensive care unit from the medical unit. Nursing management of the client should focus
on which intervention?
A. Reviewing the cause of shock and prioritizing the client’s psychosocial needs
B. Assessing and understanding shock and the significant changes in assessment
data to guide the plan of care
C. Giving the prescribed treatment, but shifting focus to providing family time as
the client is unlikely to survive
D. Promoting the client’s coping skills in an effort to better deal with the physiologic
changes accompanying shock

Answer 5

ANS: B
Rationale: Nursing care of clients in the progressive stage of shock requires expertise in
assessing and understanding shock and the significance of changes in assessment data.
Early interventions are essential to the survival of clients in shock; thus, suspecting that
a client may be in shock and reporting subtle changes in assessment are imperative.
Psychosocial needs, such as coping, are important considerations, but they are not
prioritized over physiologic health.

Question 6

The acute care nurse is providing care for an adult client who is in hypovolemic shock.
The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this
health problem. What assessment finding will the nurse likely observe related to the role
of antidiuretic hormone during hypovolemic shock?
A. Increased hunger
B. Decreased thirst
C. Decreased urinary output
D. Increased capillary perfusion

Answer 6

ANS: C
Rationale: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia
stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further
retain water in an effort to raise blood volume and blood pressure. In a hypovolemic state
the body shifts blood away from anything that is not a vital organ, so hunger is not an
issue; thirst is increased as the body tries to increase fluid volume; and capillary
profusion decreases as the body shunts blood away from the periphery and to the vital
organs.

Question 6

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ
dysfunction syndrome (MODS). The nurse’s plan of care should include what
intervention?
A. Encouraging the family to stay hopeful and educating them to the fact that, in
nearly all cases, the prognosis is good
B. Encouraging the family to leave the hospital and to take time for themselves as
acute care of MODS clients may last for several months
C. Promoting communication with the client and family along with addressing
end-of-life issues
D. Discussing organ donation on a number of different occasions to allow the family
time to adjust to the idea

Answer 6

ANS: C
Rationale: Promoting communication with the client and family is a critical role of the
nurse with a client in progressive shock. It is also important that the health care team
address end-of-life decisions to ensure that supportive therapies are congruent with the
client’s wishes. Many cases of MODS result in death, and the life expectancy of clients
with MODS is usually measured in hours and possibly days, but not in months. Organ
donation should be offered as an option on one occasion, and then allow the family time
to discuss and return to the health care providers with an answer following the death of
the client.

Question 6

When caring for a client in shock, one of the major nursing goals is to reduce the risk
that the client will develop complications of shock. How can the nurse best achieve this
goal?
A. Provide a detailed diagnosis and plan of care in order to promote the client’s and
family’s coping.
B. Keep the health care provider updated with the most accurate information
because in cases of shock the nurse often cannot provide relevant interventions.
C. Monitor for significant changes and evaluate client outcomes on a scheduled
basis focusing on blood pressure and skin temperature.
D. Understand the underlying mechanisms of shock, recognize the subtle and more
obvious signs, and then provide rapid assessment.

Answer 6

ANS: D
Rationale: Shock is a life-threatening condition with a variety of underlying causes. It is
critical that the nurse apply the nursing process as the guide for care. Shock is
unpredictable and rapidly changing so the nurse must understand the underlying
mechanisms of shock. The nurse must also be able to recognize the subtle as well as
more obvious signs and then provide rapid assessment and response to provide the client
with the best chance for recovery. Coping skills are important, but not the ultimate
priority. Keeping the health care provider updated with the most accurate information is
important, but the nurse is in the best position to provide rapid assessment and
response, which gives the client the best chance for survival. Monitoring for significant
changes is critical, and evaluating client outcomes is always a part of the nursing process,
but the subtle signs and symptoms of shock are as important as the more obvious signs,
such as blood pressure and skin temperature. Assessment must lead to diagnosis and
interventions.

Question 7

The nurse is caring for a client whose worsening infection places the client at high risk
for shock. Which assessment finding would the nurse consider a potential sign of shock?
A. Elevated systolic blood pressure
B. Elevated mean arterial pressure (MAP)
C. Shallow, rapid respirations
D. Bradycardia

Answer 7

ANS: C
Rationale: A symptom of shock is shallow, rapid respirations. Systolic blood pressure
drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock;
other states of shock have tachycardia as a symptom. Infection can lead to septic shock.

Question 8

The nurse is caring for a client in intensive care unit whose condition is deteriorating.
The nurse receives orders to initiate an infusion of dopamine. Which assessments and
interventions should the nurse prioritize?
A. Frequent monitoring of vital signs, monitoring the central line site, and providing
accurate drug titration
B. Reviewing medications, performing a focused cardiovascular assessment, and
providing client education
C. Reviewing the laboratory findings, monitoring urine output, and assessing for
peripheral edema
D. Routine monitoring of vital signs, monitoring the peripheral intravenous site,
and providing early discharge instructions

Answer 8

ANS: A
Rationale: Dopamine is a sympathomimetic agent that has varying vasoactive effects
depending on the dosage. When vasoactive medications are given, vital signs must be
monitored frequently (at least every 15 minutes until stable, or more often if indicated),
not “routinely.” Vasoactive medications should be given through a central, not
peripheral, venous line because infiltration and extravasation of some vasoactive
medications can cause tissue necrosis and sloughing. High doses can cause
vasoconstriction, which increases afterload and thus increases cardiac workload. Because
this effect is undesirable in clients with cardiogenic shock, dopamine doses must be
carefully titrated. Reviewing medications and laboratory findings, monitoring urine
output, assessing for peripheral edema, performing a focused cardiovascular
assessment, and providing client education are important nursing tasks, but they are not
specific to the administration of IV vasoactive drugs.

Question 8

The nurse in a rural nursing facility will be receiving a client in hypovolemic shock due
to a massive postpartum hemorrhage after giving birth at home. Which principle should
guide the nurse’s administration of intravenous fluid?
A. 5% albumin is preferred because it is inexpensive and is always readily
available.
B. Dextran should be given because it increases intravascular volume and
counteracts coagulopathy.
C. Whatever fluid is most readily available in the clinic should be given, due to the
nature of the emergency.
D. Lactated Ringer solution is ideal because it increases volume, buffers acidosis,
and is the best choice for clients with liver failure.

Answer 8

ANS: C
Rationale: The best fluid to treat shock remains controversial. In emergencies, the “best”
fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early
in shock to maximize intravascular volume. Both crystalloids and colloids can be
administered to restore intravascular volume. There is no consensus regarding whether
crystalloids or colloids, such as dextran and albumin, should be used; however, with
crystalloids, more fluid is necessary to restore intravascular volume. Albumin is very
expensive and is a blood product so it is not always readily available for use. Dextran
does increase intravascular volume, but it increases the risk for coagulopathy. Lactated
Ringer is a good solution choice because it increases volume and buffers acidosis, but it
should not be used in clients with liver failure because the liver is unable to convert
lactate to bicarbonate. This client does not have liver disease.

Question 9

The nurse is caring for a client who is receiving large volumes of crystalloid fluid to
treat hypovolemic shock. In light of this intervention, for what sign or symptom should
the nurse monitor?
A. Hypothermia
B. Bradycardia
C. Coffee ground emesis
D. Pain

Answer 9

ANS: A
Rationale: Temperature should be monitored closely to ensure that rapid fluid
resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during
the administration of large volumes. The nurse should monitor the client for
cardiovascular overload and pulmonary edema when large volumes of IV solution are
given. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to
cardiogenic shock.

Question 10

The nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of
possible septic shock. The nurse’s assessment reveals that the client has a normal blood
pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The
nurse’s analysis of these data should lead to which preliminary conclusion?
A. The client is in the compensatory stage of shock.
B. The client is in the progressive stage of shock.
C. The client will stabilize and be released by tomorrow.
D. The client is in the irreversible stage of shock.

Answer 10

ANS: A
Rationale: In the compensatory stage of shock, the blood pressure remains within normal
limits. Vasoconstriction, increased heart rate, and increased contractility of the heart
contribute to maintaining adequate cardiac output. Clients display the often-described
“fight or flight” response. The body shunts blood from organs such as the skin, kidneys,
and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these
vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive.
In progressive shock, the blood pressure drops. In septic shock, the client’s chance of
survival is low and he will certainly not be released within 24 hours. If the client were in
the irreversible stage of shock, his blood pressure would be very low and his organs
would be failing.

Question 11

The nurse in the intensive care unit is caring for a 47-year-old, obese client who is in
shock following a motor vehicle accident. What would be the main challenge in meeting
this client’s elevated energy requirements during prolonged rehabilitation?
A. Loss of adipose tissue
B. Loss of skeletal muscle
C. Inability to convert adipose tissue to energy
D. Inability to maintain normal body mass

Answer 11

ANS: B
Rationale: Nutritional energy requirements are met by breaking down lean body mass. In
this catabolic process, skeletal muscle mass is broken down even when the client has
large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the client’s
recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy,
and the inability to maintain normal body mass are not main concerns in meeting
nutritional energy requirements for this client.

Question 12

The nurse in the emergency department is caring for a client recently admitted with
a likely myocardial infarction (MI). The nurse understands that the client’s heart is
pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at
an increased risk for MI due to which factor?
A. Arrhythmias
B. Elevated B-natriuretic peptide (BNP)
C. Use of thrombolytics
D. Dehydration

Answer 12

ANS: A
Rationale: Cardiogenic shock occurs when the heart’s ability to pump blood is impaired
and the supply of oxygen is inadequate for the heart and tissues. An elevated BNP is
noted after an MI has occurred and does not increase risk. Use of thrombolytics
decreases risk of developing blood clots. Dehydration does not lead to MI.

Question 13

The nurse is caring for a client admitted with cardiogenic shock. The client is
experiencing chest pain and there is an order for the administration of morphine. In
addition to pain control, what is the main rationale for administering morphine to this
client?
A. It promotes coping and slows catecholamine release.
B. It stimulates the client so he or she is more alert.
C. It decreases gastric secretions.
D. It dilates the blood vessels.

Answer 13

ANS: D
Rationale: For clients experiencing chest pain, morphine is the drug of choice because it
dilates the blood vessels and controls the client’s anxiety. Morphine would not be
prescribed to promote coping or to stimulate the client. The rationale behind using
morphine would not be to decrease gastric secretions.

Question 14

The intensive care nurse is responsible for the care of a client who is in shock. What
cardiac signs or symptoms would suggest to the nurse that the client may be
experiencing acute organ dysfunction? Select all that apply.
A. Drop in systolic blood pressure of greater than or equal to 40 mm Hg from
baselines
B. Hypotension that responds to bolus fluid resuscitation
C. Exaggerated response to vasoactive medications
D. Serum lactate greater than 4 mmol/L
E. Mean arterial pressure (MAP) of less than 65 mm Hg

Answer 14

ANS: A, D, E
Rationale: Signs of acute organ dysfunction in the cardiovascular system include systolic
blood pressure <90 mm Hg or MAP <65 mm Hg, drop in systolic blood pressure >40 mm
Hg from baselines, or serum lactate >4 mmol/L. An exaggerated response to vasoactive
medications and an adequate response to fluid resuscitation would not be noted.

Question 15

The nurse is providing care for a client who is in shock after massive blood loss from
a workplace injury. The nurse recognizes that many of the findings from the most recent
assessment are due to compensatory mechanisms. What compensatory mechanism will
increase the client’s cardiac output during the hypovolemic state?
A. Third spacing of fluid
B. Dysrhythmias
C. Tachycardia
D. Gastric hypermotility

Answer 15

ANS: C
Rationale: Tachycardia is a primary compensatory mechanism to increase cardiac output
during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space.
Gastric hypermotility and dysrhythmias would not increase cardiac output and are not
considered to be compensatory mechanisms.

Question 16

An adult client has survived an episode of shock and will be discharged home to finish
the recovery phase of his disease process. The home health nurse plays an integral part
in monitoring this client. What aspect of this care should be prioritized by the home health
nurse?
A. Providing supervision to home health aides in providing necessary client care
B. Assisting the client and family to identify and mobilize community resources
C. Providing ongoing medical care during the family’s rehabilitation phase
D. Reinforcing the importance of continuous assessment with the family

Answer 16

Rationale: The home care nurse reinforces the importance of continuing medical care and
helps the client and family identify and mobilize community resources. The home health
nurse is part of a team that provides client care in the home. The nurse does not directly
supervise home health aides. The nurse provides nursing care to both the client and
family, not just the family. The nurse performs continuous and ongoing assessment of
the client; he or she does not just reinforce the importance of that assessment.

Question 17

A critical care nurse is aware of similarities and differences between the treatments
for different types of shock. What intervention is used in all types of shock?
A. Aggressive hypoglycemic control
B. Administration of hypertonic IV fluids
C. Early provision of nutritional support
D. Aggressive antibiotic therapy

Answer 17

ANS: C
Rationale: Nutritional support is necessary for all clients who are experiencing shock.
Hyperglycemic (not hypoglycemic) control is needed for many clients. Hypertonic IV
fluids are not normally utilized and antibiotics are necessary only in clients with septic
shock.

Question 18

The nurse is caring for a client in shock who is receiving enteral nutrition. What is the
basis for enteral nutrition being the preferred method of meeting the body’s needs?
A. It slows the proliferation of bacteria and viruses during shock.
B. It decreases the energy expended through the functioning of the GI system.
C. It assists in expanding the intravascular volume of the body.
D. It promotes GI function through direct exposure to nutrients.

Answer 18

ANS: D
Rationale: Parenteral or enteral nutritional support should be initiated as soon as
possible. Enteral nutrition is preferred, promoting GI function through direct exposure to
nutrients and limiting infectious complications associated with parenteral feeding. Enteral
feeding does not decrease the proliferation of microorganisms or the amount of energy
expended through the functioning of the GI system and it does not assist in expanding
the intravascular volume of the body.

Question 19

The intensive care unit nurse is caring for an acutely ill client with signs of multiple
organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing
MODS due to all of the following EXCEPT:
A. Malnutrition
B. Advanced age
C. Multiple comorbidities
D. Progressive dyspnea

Answer 19

ANS: D
Rationale: The client with advanced age is at risk for developing MODS due to the lack of
physiological reserve. The client with malnutrition metabolic compromise and the client
with multiple comorbidities is at risk for developing MODS due to decreased organ
function. Progressive dyspnea is the first sign of MODS.

Question 20

A critical care nurse is planning assessments in the knowledge that clients in shock
are vulnerable to developing fluid replacement complications. For what signs and
symptoms should the nurse monitor the client? Select all that apply.
A. Hypovolemia
B. Difficulty breathing
C. Cardiovascular overload
D. Pulmonary edema
E. Hypoglycemia

Answer 20

ANS: B, C, D
Rationale: Fluid replacement complications can occur, often when large volumes are
given rapidly. Therefore, the nurse monitors the client closely for cardiovascular
overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what
necessitates fluid replacement, and hypoglycemia is not a central concern with fluid
replacement.

Question 21

A triage nurse in the emergency department (ED) is on shift when a 4-year-old is
carried into the ED by their grandparent. The child is not breathing, and the grandparent
states the child was stung by a bee in a nearby park while they were waiting for the child’s
parent to get off work. Rapid onset of which condition would lead the nurse to suspect
that the child is experiencing anaphylactic shock?
A. Acute hypertension
B. Respiratory distress
C. Neurologic compensation
D. Cardiac arrest

Answer 21

ANS: B
Rationale: Characteristics of severe anaphylaxis usually include rapid onset of
hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur
later if prompt treatment is not provided.

Question 22

The intensive care unit nurse is caring for a client in distributive shock who is
experiencing pooling of blood in the periphery. The nurse should assess for signs and
symptoms of:
A. increased stroke volume.
B. increased cardiac output.
C. decreased heart rate.
D. decreased venous return.

Answer 22

ANS: D
Rationale: Pooling of blood in the periphery results in decreased venous return.
Decreased venous return results in decreased stroke volume and decreased cardiac
output. Decreased cardiac output, in turn, causes decreased blood pressure and,
ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the
demands of the body.

Question 23

A team of nurses are reviewing the similarities and differences between the different
classifications of shock. Which subclassifications of distributive shock should the nurses
identify? Select all that apply.
A. Anaphylactic
B. Hypovolemic
C. Cardiogenic
D. Septic
E. Neurogenic

Answer 23

ANS: A, D, E
Rationale: The varied mechanisms leading to the initial vasodilation in distributive shock
provide the basis for the further subclassification of shock into three types: septic shock,
neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not
subclassifications of distributive shock.

Question 24

The ICU nurse is caring for a client in neurogenic shock following an overdose of
antianxiety medication. When assessing this client, the nurse should recognize what
characteristic of neurogenic shock?
A. Hypertension
B. Cool, moist skin
C. Bradycardia
D. Signs of sympathetic stimulation

Answer 24

ANS: C
Rationale: In neurogenic shock, the sympathetic system is not able to respond to body
stressors. Therefore, the clinical characteristics of neurogenic shock are signs of
parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool,
moist skin seen in hypovolemic shock. Another characteristic is hypotension with
bradycardia, rather than the tachycardia that characterizes other forms of shock.

Question 24

The ICU nurse caring for a client in shock is administering vasoactive medications as
per orders. The nurse should administer this medication in what way?
A. Through a central venous line
B. By a gravity infusion IV set
C. By IV push for rapid onset of action
D. Mixed with parenteral feedings to balance osmosis

Answer 24

ANS: A
Rationale: Whenever possible, vasoactive medications should be given through a central
venous line because infiltration and extravasation of some vasoactive medications can
cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure
that the medications are delivered safely and accurately. They are never mixed with
parenteral nutrition.

Question 25

A client is being treated in the ICU for neurogenic shock secondary to a spinal cord
injury. Despite aggressive interventions, the client’s mean arterial pressure (MAP) has
fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by
referring to what laboratory findings? Select all that apply.
A. Blood urea nitrogen (BUN) level
B. Urine specific gravity
C. Alkaline phosphatase level
D. Creatinine level
E. Serum albumin level

Answer 25

ANS: A, B, D
Rationale: Acute kidney injury (AKI) is characterized by an increase in BUN and serum
creatinine levels, fluid and electrolyte shifts, acid–base imbalances, and a loss of the
renal–hormonal regulation of BP. Urine specific gravity is also affected. Alkaline
phosphatase and albumin levels are related to hepatic function.

Question 25

The intensive care unit nurse is caring for a client with sepsis whose tissue perfusion
is declining. What sign would indicate to the nurse that end-organ damage may be
occurring?
A. Urinary output increases
B. Skin becomes warm and dry
C. Adventitious lung sounds occur in the upper airway
D. Heart and respiratory rates are elevated

Answer 25

ANS: D
Rationale: As sepsis progresses, tissues become less perfused and acidotic,
compensation begins to fail, and the client begins to show signs of organ dysfunction. The
cardiovascular system also begins to fail, the blood pressure does not respond to fluid
resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g.,
acute kidney injury, pulmonary failure, hepatic failure). As sepsis progresses to septic
shock, the blood pressure drops, and the skin becomes cool, pale, and mottled.
Temperature may be normal or below normal. Heart and respiratory rates remain rapid.
Urine production ceases, and multiple organ dysfunction progressing to death occurs.
Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of
the lungs.

Question 25

The ICU nurse is caring for a client in hypovolemic shock following a postpartum
hemorrhage. For what serious complication of treatment should the nurse monitor the
client?
A. Anaphylaxis
B. Decreased oxygen consumption
C. Abdominal compartment syndrome
D. Decreased serum osmolality

Answer 25

ANS: C
Rationale: Abdominal compartment syndrome (ACS) is a serious complication that may
occur when large volumes of fluid are given. The scenario does not describe an antigen–
antibody reaction of any type. Decreased oxygen consumption by the body is not a
concern in hypovolemic shock. With a decrease in fluids in the intravascular space,
increased serum osmolality would occur.

Question 26

The critical care nurse is preparing to initiate an infusion of a vasoactive medication
to a client in shock. What goal of this treatment should the nurse identify?
A. Absence of infarcts or emboli
B. Reduced stroke volume and cardiac output
C. Absence of pulmonary and peripheral edema
D. Maintenance of adequate mean arterial pressure

Answer 26

ANS: D
Rationale: Vasoactive medications can be given in all forms of shock to improve the
client’s hemodynamic stability when fluid therapy alone cannot maintain adequate MAP.
Specific medications are selected to correct the particular hemodynamic alteration that is
impeding cardiac output. These medications help increase the strength of myocardial
contractility, regulate the heart rate, reduce myocardial resistance, and initiate
vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.

Question 27

An 11-year-old client has been brought to the emergency department by their
parent, who reports that the client may be having a “really bad allergic reaction to
peanuts” after trading lunches with a peer. The triage nurse’s rapid assessment reveals
the presence of respiratory and cardiac arrest. Which interventions should the nurse
prioritize?
A. Establishing central venous access and beginning fluid resuscitation
B. Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
C. Establishing peripheral intravenous (IV) access and administering IV
epinephrine
D. Performing a comprehensive assessment and initiating rapid fluid replacement

Answer 27

ANS: B
Rationale: If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is
performed. A patent airway is also an immediate priority. Epinephrine is not withheld
pending IV access, and fluid resuscitation is not a priority.

Question 28

A client is responding poorly to interventions aimed at treating shock and appears to
be transitioning to the irreversible stage of shock. What action should the intensive care
nurse include during this phase of the client’s care?
A. Communicate clearly and frequently with the client’s family.
B. Taper down interventions slowly when the prognosis worsens.
C. Transfer the client to a subacute unit when recovery appears unlikely.
D. Ask the client’s family how they would prefer treatment to proceed.

Answer 28

ANS: A
Rationale: As it becomes obvious that the client is unlikely to survive, the family must be
informed about the prognosis and likely outcome. Opportunities should be provided
throughout the client’s care for the family to see, touch, and talk to the client. However,
the onus should not be placed on the family to guide care. Interventions are not normally
reduced gradually when they are deemed ineffective; instead, they are discontinued
when they appear futile. The client would not be transferred to a subacute unit.

Question 29

A critical care nurse is aware of the high incidence of ventilator-associated pneumonia
(VAP) in clients who are being treated for shock. What intervention should be specified in
the client’s plan of care while the client is ventilated?
A. Performing frequent oral care
B. Maintaining the client in a supine position
C. Suctioning the client every 15 minutes unless contraindicated
D. Administering prophylactic antibiotics, as prescribed

Answer 29

ANS: A
Rationale: Nursing interventions that reduce the incidence of VAP must also be
implemented. These include frequent oral care, aseptic suction technique, turning, and
elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should
not be excessively frequent and prophylactic antibiotics are not normally indicated.

Question 30

An immunocompromised 65-year-old client has developed a urinary tract infection,
and the care team recognizes the need to prevent an exacerbation of the client’s infection
that could result in urosepsis and septic shock. Which action should the nurse perform to
reduce the client’s risk of septic shock?
A. Apply an antibiotic ointment to the client’s mucous membranes, as prescribed.
B. Perform passive range-of-motion exercises unless contraindicated.
C. Initiate total parenteral nutrition (TPN).
D. Remove invasive devices as soon as they are no longer needed.

Answer 30

ANS: D
Rationale: Early removal of invasive devices can reduce the incidence of infections. Broad
application of antibiotic ointments is not performed. TPN may be needed, but this does
not directly reduce the risk of further infection. Range-of-motion exercises are not a
relevant intervention.