Question 1

The nurse is aware that immobility and insertion of urinary catheters,although therapeutic,also places the patient at risk for _________________________.

Accepted Answer

Infection
The insertion of a Foley catheter and long-term immobility can cause infections.

Question 2

One of the most important assessments that the nurse makes is to check urine output.The value that objectively validates minimal acceptable renal perfusion for the average-size person is:

Accepted Answer

A)   0.5 ml/kg/hr
B)   0.5 ml/lb/hr
C)   1 ml/lb/hr
D)   0.2 ml/kg/hr A

Question 3

The nurse explains that the use of medical antishock trousers (MAST)garment compress the legs and abdomen to:

Accepted Answer

A)   Help restore cellular perfusion.
B)   Decrease internal hemorrhage.
C)   Cool the patient to create less metabolic demand.
D)   Apply pressure during the systole phase and relax pressure during the diastole phase. A

Question 4

The nurse caring for a patient who has a cervical spine injury immediately documents and reports the assessment of progressive hypotension as a sign of probable:

Accepted Answer

A)   Anaphylaxis
B)   Respiratory alkalosis
C)   Multiple organ dysfunction syndrome (MODS) 
D)   Neurogenic shock

Question 5

The stages of shock proceed in a definite sequence.What is the correct order?

Accepted Answer

A)   Progressive, compensatory, refractory
B)   Refractory, progressive, compensatory
C)   Compensatory, progressive, refractory
D)   Distributive, compensatory, refractory

Question 6

The nurse explains to a concerned family member about the purpose of some of the interventions for systemic inflammatory response syndrome (SIRS),which is:

Accepted Answer

A)   Applying a MAST garment to promote and conserve body heat.
B)   Inserting an IABP to decrease fluid leaking into the extravascular space.
C)   Maintaining strict isolation to prevent an overlying bacterial infection.
D)   Aggressively treating to support the multiple failing organs.

Question 7

The position that would enhance cerebral blood flow to counteract the symptoms of compensatory shock is:

Accepted Answer

A)   Fowler
B)   Trendelenburg
C)   Gravity neutral
D)   Sidelying

Question 8

Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock,shock itself results from failure of which system?

Accepted Answer

A)   Circulatory
B)   Endocrine
C)   Neurologic
D)   Respiratory

Question 9

The nurse is administering dopamine to the patient to treat the shock syndrome.The expected action of this drug is as a(n):

Accepted Answer

A)   Alpha-adrenergic agonist
B)   Beta-adrenergic agonist
C)   Alpha- and beta-adrenergic agonist
D)   Inotropic agent

Question 10

The nurse explains that pericardial tamponade and pulmonary embolus can place the patient at risk for ______________ shock.

Accepted Answer

The answer of The nurse explains that pericardial tamponade and...

Question 11

Because of the falling blood pressure and impaired blood circulation during the refractory stage of shock,the nurse expects that the respirations will be:

Accepted Answer

A)   Rapid and deep
B)   Rapid and shallow
C)   Slow and deep
D)   Slow and shallow

Question 12

The nurse explains that when shock forces the body into anaerobic metabolism,organ damage is caused by a product of that metabolism,which is ____________________.

Accepted Answer

The answer of The nurse explains that when shock forces...

Question 13

When speaking to the family of a 65-year-old Hispanic woman,the nurse will address most conversation to the:

Accepted Answer

A)   66-year-old husband
B)   Entire family, in general
C)   42-year-old daughter (oldest child) 
D)   40-year-old son (only son)

Question 14

In the compensatory stage of shock,the nurse would need to implement actions to care for the patient who is:

Accepted Answer

A)   Irritable and restless
B)   Listless and confused
C)   Unconscious
D)   Anxious and fearful

Question 15

The nurse is administering heparin,subcutaneous twice daily,for a patient in cardiogenic shock.The expected action of this drug is as a(n):

Accepted Answer

A)   Inotropic to improve cardiac contractibility
B)   Anticoagulant to prevent blood clots
C)   Antidysrhythmic to restore normal cardiac contractibility
D)   Vasopressor to increase blood pressure

Question 16

The nurse explains that the minimal acceptable hourly urine output for the patient in shock who weighs 220 pounds is ____________________.

Accepted Answer

The answer of The nurse explains that the minimal acceptable...

Question 17

The nurse assessing a patient in the progressive stage of shock would expect to find:

Accepted Answer

A)   Bounding pulse, decreased respirations, and decreased blood pressure
B)   Bounding pulse, shallow respirations, and significantly increased blood pressure
C)   Thready pulse and deep respirations with decreased blood pressure
D)   Thready pulse and irregular respirations with increased blood pressure

Question 18

When a family member asks why her father,who is being treated for cardiogenic shock,needs parenteral feeding since he is capable of eating small amounts,the nurse replies that the parenteral feedings:

Accepted Answer

A)   Reduce the risk of constipation.
B)   Meet the patient's hypermetabolic needs.
C)   Are more convenient and less time consuming .
D)   Decrease the hazard of infection.

Question 19

While shopping in the mall,the nurse sees a lady suddenly fall to the floor.On immediate assessment,the nurse realizes she is not in cardiac arrest and has no need for cardiopulmonary resuscitation (CPR).The immediate actions by the nurse are to:

Accepted Answer

A)   Check the pulse and respirations, and call for a blood pressure cuff.
B)   Check the pulse, respirations, skin color, and temperature.
C)   Call for help and check the pulse, respiration, and mental status.
D)   Ask someone to help place large blankets or coats under her legs and trunk.

Question 20

The nurse reviews the four types of shock,which are:

Accepted Answer

A)   Multiple organ, cardiogenic, renal, and anaphylactic
B)   Cardiogenic, renal, hypovolemic, and septic
C)   Renal, hypervolemic, obstructive shock, and neurogenic
D)   Hypovolemic, cardiogenic, obstructive shock, and vasogenic

Exam 19: Shock