Hinkle 11

Question 1

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

B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients.

Question 2

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

A. Fluid volume circulating in the blood vessels decreases.

Question 3

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

D. Cool, clammy skin

Question 4

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

A. Lactated Ringer

Question 5

5. 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 5

B. The drug dose should be tapered down once vital signs improve.

Question 6

6. 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 6

B. Neurogenic shock

Question 7

7. 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 7

C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements

Question 8

8. 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 8

B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care

Question 9

9. 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 9

D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

Question 10

10. 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 10

C. Promoting communication with the client and family along with addressing end-of-life issues

Question 11

11. 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 11

C. Decreased urinary output

Question 12

12. 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 12

C. Shallow, rapid respirations

Question 13

13. 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 13

A. Hypothermia

Question 14

14. 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 14

A. Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration

Question 15

15. 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 15

A. The client is in the compensatory stage of shock.

Question 16

16. 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 16

C. Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency.

Question 17

17. 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 17

B. Loss of skeletal muscle

Question 18

18. 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 18

A. Arrhythmias

Question 19

19. 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 19

D. It dilates the blood vessels.

Question 20

20. 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 20

C. Tachycardia

Question 21

21. 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 21

A. Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines
D. Serum lactate greater than 4 mmol/L
E. Mean arterial pressure (MAP) of less than 65 mm Hg

Question 22

22. 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 22

B. Assisting the client and family to identify and mobilize community resources

Question 23

23. 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 23

C. Early provision of nutritional support

Question 24

24. 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 24

D. It promotes GI function through direct exposure to nutrients.

Question 25

25. 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 25

D. Progressive dyspnea

Question 26

26. 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 26

B. Difficulty breathing
C. Cardiovascular overload
D. Pulmonary edema

Question 27

27. 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 27

D. decreased venous return.

Question 28

28. 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 28

A. Anaphylactic
D. Septic
E. Neurogenic

Question 29

29. 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 29

B. Respiratory distress

Question 30

30. 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 30

C. Bradycardia

Question 31

31. 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 31

D. Maintenance of adequate mean arterial pressure

Question 32

32. 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 32

A. Through a central venous line

Question 33

33. 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 33

C. Abdominal compartment syndrome

Question 34

34. 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 34

D. Heart and respiratory rates are elevated

Question 35

35. 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 35

B. Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)

Question 36

36. 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 36

A. Communicate clearly and frequently with the client’s family.

Question 37

37. 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 37

A. Performing frequent oral care

Question 38

38. 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 38

A. Blood urea nitrogen (BUN) level
B. Urine specific gravity
D. Creatinine level

Question 39

39. 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 39

D. Remove invasive devices as soon as they are no longer needed.