Test
Critical Care Questions Chapter 11
Preguntas del test (39)
1A 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?
- ABlood is shunted from vital organs to peripheral areas of the body.
- BCells lack an adequate blood supply and are deprived of oxygen and nutrients.
- CCirculating blood volume is decreased with a resulting change in the osmotic pressure gradient.
- DHemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
2In 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?
- AFluid volume circulating in the blood vessels decreases.
- BThere is an uncontrolled increase in cardiac output.
- CBlood pressure regulation becomes irregular.
- DThe client experiences tachycardia and a bounding pulse.
3The 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?
- AIncreased urine output
- BDecreased heart rate
- CHyperactive bowel sounds
- DCool, clammy skin
4The 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?
- ALactated Ringer
- BAlbumin
- CDextran
- D3% NaCl
5A 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?
- AThe drug should be discontinued immediately after blood pressure increases.
- BThe drug dose should be tapered down once vital signs improve.
- CThe client should have arterial blood gases drawn every 10 minutes during treatment.
- DThe infusion rate should be titrated according the client's subjective sensation of adequate perfusion.
6A 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?
- AAnaphylactic shock
- BNeurogenic shock
- CSeptic shock
- DHypovolemic shock
7The 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?
- AThe use of albumin as an energy source by the body because of the need for increased adenosine triphosphate
- BThe loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity
- CThe release of catecholamines that creates an increase in metabolic rate and caloric requirements
- DThe increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea
8The 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?
- AReviewing the cause of shock and prioritizing the client's psychosocial needs
- BAssessing and understanding shock and the significant changes in assessment data to guide the plan of care
- CGiving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive
- DPromoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock
9When 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?
- AProvide a detailed diagnosis and plan of care in order to promote the client's and family's coping.
- BKeep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions.
- CMonitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature.
- DUnderstand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
10The 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?
- AEncouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good
- BEncouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months
- CPromoting communication with the client and family along with addressing end-of-life issues
- DDiscussing organ donation on a number of different occasions to allow the family time to adjust to the idea
11The 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?
- AIncreased hunger
- BDecreased thirst
- CDecreased urinary output
- DIncreased capillary perfusion
12The 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?
- AElevated systolic blood pressure
- BElevated mean arterial pressure (MAP)
- CShallow, rapid respirations
- DBradycardia
13The 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?
- AHypothermia
- BBradycardia
- CCoffee ground emesis
- DPain
14The 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?
- AFrequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration
- BReviewing medications, performing a focused cardiovascular assessment, and providing client education
- CReviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema
- DRoutine monitoring of vital signs, monitoring the peripheral intravenous site, and providing early discharge instructions
15The 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?
- AThe client is in the compensatory stage of shock.
- BThe client is in the progressive stage of shock.
- CThe client will stabilize and be released by tomorrow.
- DThe client is in the irreversible stage of shock.
16The 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?
- A5% albumin is preferred because it is inexpensive and is always readily available.
- BDextran should be given because it increases intravascular volume and counteracts coagulopathy.
- CWhatever fluid is most readily available in the clinic should be given, due to the nature of the emergency.
- DLactated Ringer solution is ideal because it increases volume, buffers acidosis, and is the best choice for clients with liver failure.
17The 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?
- ALoss of adipose tissue
- BLoss of skeletal muscle
- CInability to convert adipose tissue to energy
- DInability to maintain normal body mass
18The 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?
- AArrhythmias
- BElevated B-natriuretic peptide (BNP)
- CUse of thrombolytics
- DDehydration
19The 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?
- AIt promotes coping and slows catecholamine release.
- BIt stimulates the client so he or she is more alert.
- CIt decreases gastric secretions.
- DIt dilates the blood vessels.
20The 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?
- AThird spacing of fluid
- BDysrhythmias
- CTachycardia
- DGastric hypermotility
21The 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.
- ADrop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines
- BHypotension that responds to bolus fluid resuscitation
- CExaggerated response to vasoactive medications
- DSerum lactate greater than 4 mmol/L
- EMean arterial pressure (MAP) of less than 65 mm Hg
22An 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?
- AProviding supervision to home health aides in providing necessary client care
- BAssisting the client and family to identify and mobilize community resources
- CProviding ongoing medical care during the family's rehabilitation phase
- DReinforcing the importance of continuous assessment with the family
23A 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?
- AAggressive hypoglycemic control
- BAdministration of hypertonic IV fluids
- CEarly provision of nutritional support
- DAggressive antibiotic therapy
24The 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?
- AIt slows the proliferation of bacteria and viruses during shock.
- BIt decreases the energy expended through the functioning of the GI system.
- CIt assists in expanding the intravascular volume of the body.
- DIt promotes GI function through direct exposure to nutrients.
25The 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:
- AMalnutrition
- BAdvanced age
- CMultiple comorbidities
- DProgressive dyspnea
26A 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.
- AHypovolemia
- BDifficulty breathing
- CCardiovascular overload
- DPulmonary edema
- EHypoglycemia
27The 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:
- Aincreased stroke volume.
- Bincreased cardiac output.
- Cdecreased heart rate.
- Ddecreased venous return.
28A 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.
- AAnaphylactic
- BHypovolemic
- CCardiogenic
- DSeptic
- ENeurogenic
29A 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?
- AAcute hypertension
- BRespiratory distress
- CNeurologic compensation
- DCardiac arrest
30The 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?
- AHypertension
- BCool, moist skin
- CBradycardia
- DSigns of sympathetic stimulation
31The 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?
- AAbsence of infarcts or emboli
- BReduced stroke volume and cardiac output
- CAbsence of pulmonary and peripheral edema
- DMaintenance of adequate mean arterial pressure
32The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way?
- AThrough a central venous line
- BBy a gravity infusion IV set
- CBy IV push for rapid onset of action
- DMixed with parenteral feedings to balance osmosis
33The 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?
- AAnaphylaxis
- BDecreased oxygen consumption
- CAbdominal compartment syndrome
- DDecreased serum osmolality
34The 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?
- AUrinary output increases
- BSkin becomes warm and dry
- CAdventitious lung sounds occur in the upper airway
- DHeart and respiratory rates are elevated
35An 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?
- AEstablishing central venous access and beginning fluid resuscitation
- BEstablishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
- CEstablishing peripheral intravenous (IV) access and administering IV epinephrine
- DPerforming a comprehensive assessment and initiating rapid fluid replacement
36A 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?
- ACommunicate clearly and frequently with the client's family.
- BTaper down interventions slowly when the prognosis worsens.
- CTransfer the client to a subacute unit when recovery appears unlikely.
- DAsk the client's family how they would prefer treatment to proceed.
37A 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?
- APerforming frequent oral care
- BMaintaining the client in a supine position
- CSuctioning the client every 15 minutes unless contraindicated
- DAdministering prophylactic antibiotics, as prescribed
38A 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.
- ABlood urea nitrogen (BUN) level
- BUrine specific gravity
- CAlkaline phosphatase level
- DCreatinine level
- ESerum albumin level
39An 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?
- AApply an antibiotic ointment to the client's mucous membranes, as prescribed.
- BPerform passive range-of-motion exercises unless contraindicated.
- CInitiate total parenteral nutrition (TPN).
- DRemove invasive devices as soon as they are no longer needed.
Información
- Descripción
- Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
- Autor
- Donut Docks-Mii
- Idioma
- English
- Visitas
- 47
- Etiquetas
- Valoración
- Aún sin valoraciones Valora este test