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Chapter 34: Critical Care of Patients With
Shock Ignatavicius: Medical-Surgical
Nursing, 10th Edition Verified and Updated
Questions and Answers (100% Correct
Answers)
1. A nurse is caring for a client who suffered massive blood loss after trauma. How
does the nurse correlate the blood loss with the client's mean arterial pressure
(MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
Answer: ANS: B Lower blood volume will decrease MAP. The other answers are not
accurate.
2. A nurse is caring for a client after surgery. The client's respiratory rate has
increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98
beats/min since the client was last assessed 4 hours ago. What action by the nurse is
best?
a. Ask if the client needs pain medication.
b. Assess using the MEWS score.
c. Document the findings in the client's chart.
d. Increase the rate of the client's IV infusion.
Answer: ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases in
heart rate, respiratory rate, or blood pressure. Even though these readings are not
out of the normal range, the nurse would conduct a thorough assessment of the
patient, focusing on indicators of perfusion. The MEWS score (Modified Early Warning
Score) was developed to identify clients at risk for deterioration. The client may need
pain medication, but this is not the priority at this time. Documentation would be
, Inquire through: | Professional | Confidential Support
done thoroughly but would be done after the assessment. The nurse would not
increase the rate of the IV infusion without an order
3. The nurse gets the hand-off report on four clients. Which client would the nurse
assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hou
Answer: ANS: A
This client has a falling systolic blood pressure, rising diastolic blood pressure, and
narrowing pulse pressure, all of which may be indications of worsening perfusion
status and possible shock. The nurse would assess this client first. The client with
the unchanged oxygen saturation is stable at this point. Although the client with a
change in pulse has a slower rate, it is not an indicator of shock since the pulse is
still within the normal range; it may indicate that the client's pain or anxiety has
been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is
above the normal range, which is 30 mL/hr.
4. A nurse is caring for a client after surgery who is restless and apprehensive. The
assistive personnel (AP) reports the vital signs and the nurse sees that they are only
slightly different from previous readings. What action does the nurse delegate next
to the AP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the side.
d. Stay with the client and reassure him or her.
Answer: ANS: B
Urine output changes are a sensitive early indicator of shock. The nurse would
delegate emptying the urinary catheter and measuring output to the AP as a baseline
for hourly urine output measurements. The AP cannot assess for pain. Repositioning
may or may not be effective for decreasing restlessness, but does not take priority
Chapter 34: Critical Care of Patients With
Shock Ignatavicius: Medical-Surgical
Nursing, 10th Edition Verified and Updated
Questions and Answers (100% Correct
Answers)
1. A nurse is caring for a client who suffered massive blood loss after trauma. How
does the nurse correlate the blood loss with the client's mean arterial pressure
(MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
Answer: ANS: B Lower blood volume will decrease MAP. The other answers are not
accurate.
2. A nurse is caring for a client after surgery. The client's respiratory rate has
increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98
beats/min since the client was last assessed 4 hours ago. What action by the nurse is
best?
a. Ask if the client needs pain medication.
b. Assess using the MEWS score.
c. Document the findings in the client's chart.
d. Increase the rate of the client's IV infusion.
Answer: ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases in
heart rate, respiratory rate, or blood pressure. Even though these readings are not
out of the normal range, the nurse would conduct a thorough assessment of the
patient, focusing on indicators of perfusion. The MEWS score (Modified Early Warning
Score) was developed to identify clients at risk for deterioration. The client may need
pain medication, but this is not the priority at this time. Documentation would be
, Inquire through: | Professional | Confidential Support
done thoroughly but would be done after the assessment. The nurse would not
increase the rate of the IV infusion without an order
3. The nurse gets the hand-off report on four clients. Which client would the nurse
assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hou
Answer: ANS: A
This client has a falling systolic blood pressure, rising diastolic blood pressure, and
narrowing pulse pressure, all of which may be indications of worsening perfusion
status and possible shock. The nurse would assess this client first. The client with
the unchanged oxygen saturation is stable at this point. Although the client with a
change in pulse has a slower rate, it is not an indicator of shock since the pulse is
still within the normal range; it may indicate that the client's pain or anxiety has
been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is
above the normal range, which is 30 mL/hr.
4. A nurse is caring for a client after surgery who is restless and apprehensive. The
assistive personnel (AP) reports the vital signs and the nurse sees that they are only
slightly different from previous readings. What action does the nurse delegate next
to the AP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the side.
d. Stay with the client and reassure him or her.
Answer: ANS: B
Urine output changes are a sensitive early indicator of shock. The nurse would
delegate emptying the urinary catheter and measuring output to the AP as a baseline
for hourly urine output measurements. The AP cannot assess for pain. Repositioning
may or may not be effective for decreasing restlessness, but does not take priority
