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NURSING MANAGEMENT: SHOCK & MODS (NCLEX)QUESTIONS WITH CORRECT ANSWERS

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A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. checks the blood pressure. b. obtains an oxygen saturation. c. att... aches a cardiac monitor. d. check level of consciousness. Correct Answer 1. Correct Answer: B Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed. 2. A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thread; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the a. progressive stage of septic shock. b. compensatory stage of diabetic shock. c. refractory stage of cardiogenic shock. d. progressive stage of hypovolemic shock. Correct Answer Correct Answer: D Rationale: The patient's history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with hypovolemia, and the symptoms are most consistent with the progressive stage of shock. The patient's temperature of 97° F is inconsistent with septic shock. The history is inconsistent with a diagnosis of cardiogenic shock, and the patient's neurologic status is not consistent with refractory shock. [Show More]

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