Chapter 9. Nursing Care of Patients in Shock
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A patient who has gastrointestinal bleeding is awake, alert, and or
...
Chapter 9. Nursing Care of Patients in Shock
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A patient who has gastrointestinal bleeding is awake, alert, and oriented. The patient’s vital signs are: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C).
Which of this patient’s data collection findings should the nurse consider as a possible sign of early shock?
a. Blood pressure 130/90 mm Hg
b. Heart rate 118 beats/min
c. Respirations 18/min
d. Temperature 98.6°F (37°C)
2. A patient with gastrointestinal bleeding has a hemoglobin of 8.5 g/dL. As the nurse assists the patient, who is anxious and irritable, the patient’s nasogastric drainage becomes bright red, pulse 130 beats/minute, blood pressure 105/55 mm Hg, respirations 28/minute. The nurse recognizes which of the following is likely respon- sible for the changes in the patient’s vital signs?
a. Early shock
b. Patient anxiety
c. Progressive shock
d. Parasympathetic response
3. Data collection findings for a patient involved in a motor vehicle accident include pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which of these does the nurse recognize as the likely cause of this acidosis?
a. Inadequate ventilation
b. Hyperventilation
c. Aerobic metabolism
d. Anaerobic metabolism
4. A patient experiencing progressive shock is diaphoretic, is confused, has a blood pressure of 82/40 mm Hg, and has a urinary catheter output of 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr.
Which action should the nurse take related to the urine output?
a. Irrigate urinary catheter.
b. Encourage oral fluids.
c. Check urinary catheter for kinking.
d. Increase IV fluid infusion rate.
5. The nurse is caring for a patient who has hypovolemic shock and oliguria due to hemorrhage. The nurse rec- ognizes that which of the following is the most likely cause of the patient’s oliguria?
a. Inadequate oral fluid intake
b. Secretion of aldosterone
c. End-stage renal failure
d. Obstructed urinary catheter
6. On arrival in the emergency department, a patient who was in a motor vehicle accident is reported to be ap- prehensive, confused, hypotensive, tachycardic, and oliguric, with cool and clammy skin. What should the nurse do first?
a. Perform a rapid head-to-toe assessment.
b. Obtain patient’s medical history from family.
c. Cover patient with warm blankets.
d. Reorient the patient to person, place, and time.
7. A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160 beats/minute, and respirations 30/minute. The patient is receiving intravenous fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. Which of the following does the nurse recognize as the most likely cause of the patient’s respiratory rate?
a. Electrolyte imbalances
b. Inadequate tissue perfusion
c. Reaction to the blood transfusion
d. Rapid rate of fluid replacement
8. Despite aggressive treatment, the condition of a patient who is in shock continues to worsen. Surgical inter- vention stops the bleeding, and the shock stabilizes. Which of the following findings would require immediate action by the nurse?
a. Pupils are equally reactive to light.
b. Bowel sounds are hypoactive.
c. Urinary output is 15 mL/hour.
d. The blood pH is 7.36.
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