Exam 9: Nursing Care of Patients in Shock

The nurse can expect a patient who lost 2 liters of blood during surgery to experience which type of shock?

The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.)

The nurse is teaching a patient how to administer epinephrine 0.5 mg intramuscularly. The available dose is 0.5 mg/0.5 mL. How many mL will the patient be taught to administer? Enter the numeral only.

A patient with gastrointestinal bleeding is awake, alert, and oriented and has the following vital sign measurements: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock?

Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical intervention stops the bleeding and the shock stabilizes. Which finding should the nurse act on immediately?

The nurse knows early in shock, blood is shunted away from the kidneys. How long can the kidneys tolerate reduced blood flow before cells begin to die?

On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive, confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the nurse do first?

The nurse has been informed a patient suffered injury to the liver caused by ischemia. What can the nurse expect to find?

A patient is developing anaphylactic shock. What should the nurse expect to observe in this patient? (Select all that apply.)

A patient with a history of a myocardial infarction has chest pain. The patient's skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take?

The nurse is reviewing orders for a patient in anaphylactic shock. Which medication should the nurse plan to administer first?

The nurse is caring for an 85-year-old patient with septic shock. What should the nurse keep in mind when repositioning this patient?

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 IV fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the most likely cause of the patient's respiratory rate?

The nurse is receiving report on patients assigned for the next shift. Which patient should the nurse observe first?

The nurse is caring for a patient with stroke. Which does the nurse identify as complications of this condition? (Select all that apply.)

A patient in shock is diagnosed with metabolic acidosis. What should the nurse realize as being the mechanism behind the development of this acid-base imbalance?

The nurse is preparing to administer 1 liter of 0.9% NS over 2 hours intravenously to a patient experiencing shock. At what rate will the nurse set the infusion pump? Enter the numeral only.

A patient in shock is being transported to the nearest emergency department. Upon arrival, in which order should the nurse provide care? Place the actions in the order that they should be performed from 1 to 6. ___ A) Ensure breathing. ___ B) Secure an airway. ___ C) Assess level of consciousness. ___ D) Prepare for x-rays and other tests. ___ E) Apply pressure to bleeding wounds. ___ F) Monitor heart rate and blood pressure.

Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday, report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which order should the nurse question?

The unlicensed assistive personnel (UAP) reports the following to the nurse. Which patient should the nurse see first based on this information?