Exam 9: Nursing Care of Patients in Shock

After an episode of shock,a patient's laboratory results reveal elevated serum levels of ammonia and bilirubin and decreased plasma proteins and clotting factors.Which organ should the nurse recognize as being damaged from the shock?

A patient with hypovolemic shock is experiencing oliguria due to hemorrhage.Which should the nurse recognize as the most likely cause of the patient's oliguria?

A patient is admitted with suspected septic shock.Which action should the nurse take first?

A patient is experiencing respiratory distress and mild shock.In which position should the nurse place the patient?

As part of ongoing data collection and care of a patient in shock,the nurse notes a slowing heart rate,systolic blood pressure less than 60 mm Hg,a decreasing temperature,decreasing respiration rate,and scant urine output.These signs and symptoms should indicate to the nurse that the patient is in which stage of shock?

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?

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 upon immediately?

The nurse discovers that a patient recovering from surgery is hemorrhaging from the incisional site.What action should the nurse take?

A patient involved in a motor vehicle accident has pale mucous membranes,diaphoresis,confusion,blood pressure 88/48 mm Hg,irregular heart rhythm,and metabolic acidosis.Which finding should the nurse recognize as the likely cause of acidosis?

The nurse determines that a patient with hypovolemic shock is improving.What did the nurse observe to come to this conclusion? (Select all that apply.)

A patient in shock is found unresponsive.The nurse knows that immediate cardiopulmonary resuscitation is required because brain cells begin to die if deprived of oxygen for how many minutes?

The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock.What should the nurse do if the patient's urine output drops to 15 mL for one hour of monitoring?

The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a patient who is experiencing shock.What is the purpose of the nurse performing these actions?

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.

A patient is demonstrating signs of anaphylactic shock.What action should the nurse take first?

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.)

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?

A patient recovering from vascular leg surgery is found standing in a large pool of blood flowing from the surgical site.After assisted into bed,the patient is pale with a palpable pulse.What action should the nurse take?

The family of a patient in shock asks the nurse to explain the condition.How should the nurse respond to this family?

A patient in shock has a falling blood pressure.What should the nurse realize occurs as the sympathetic nervous system responds to falling blood pressure? (Select all that apply.)