NR EXAMvc
Exam Solution vc
Shock Sepsis and Multiple Organ Dysfunction Syndrom vc vc vc vc vc vc
e 2026 A+ GRADE ASSURED COMPLETE SOLUTIONS AN
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D VERIFIED ANSWERS (D0ED0)
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QUESTION 1 vc
3. A 19-year-
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old patient with massive trauma and possible spinal cord injury is admitted to the emerg
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ency department (ED). Which assessment finding by the nurse will help confirm a diagno
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sis of neurogenic shock?
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a. Inspiratory crackles.
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b. Cool, clammy extremities.
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c. Apical heart rate 45 beats/min.
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d. Temperature 101.2 F (38.4 C).
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ANSWER
ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be
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more consistent with other types of shock.
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QUESTION 2 vc
5. After receiving 2 L of normal saline, the central venous pressure for a patient who has
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septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will an
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ticipate an order for vc vc vc
a. nitroglycerine (Tridil).
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b. norepinephrine (Levophed).
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c. sodium nitroprusside (Nipride).
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d. methylprednisolone (Solu-Medrol).
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ANSWER
ANS: B When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the syst
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emic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would d
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ecrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-
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Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside
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is an arterial vasodilator and would further decrease SVR. Normal CVP is between 2-
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6. In septic shock, first give fluids, then vasopressors, then steroids.
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,QUESTION 3 vc
6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with
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systemic inflammatory response syndrome (SIRS), which assessment will the nurse perf
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orm?
a. Auscultate bowel sounds.
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b. Palpate for abdominal pain.
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c. Ask the patient about nausea.
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d. Check stools for occult blood.
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ANSWER
ANS: D Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. T
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he other assessments also will be done, but these will not help in determining the effectiveness of the p
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antoprazole administration. vc
QUESTION 4 vc
7. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, r
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espirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac o
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utput is low. The nurse will anticipate an order for which medication?
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a. 5% human albumin
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b. Furosemide (Lasix) IV
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c. Epinephrine (Adrenalin) drip
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d. Hydrocortisone (Solu-Cortef)
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ANSWER
ANS: B The PAWP indicates that the patients preload is elevated, and furosemide is indicated to reduce
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the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial
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oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considere
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d for septic or anaphylactic shock.
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QUESTION 5 vc
8. The emergency department (ED) nurse receives report that a patient involved in a mo
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tor vehicle crash is being transported to the facility with an estimated arrival in 1 minut
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e. In preparation for the patients arrival, the nurse will obtain
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a. hypothermia blanket.
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b. lactated Ringers solution.
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c. two 14-gauge IV catheters.
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d. dopamine (Intropin) infusion.
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ANSWER
ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic s
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hock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactate
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d Ringers solution should be used cautiously and will not be ordered until the patient has been assessed
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, for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic
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shock. Patients in shock need to be kept warm not cool.
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QUESTION 6 vc
9. Which finding is the best indicator that the fluid resuscitation for a patient with hypov
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olemic shock has been effective? vc vc vc vc
a. Hemoglobin is within normal limits.
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b. Urine output is 60 mL over the last hour.
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c. Central venous pressure (CVP) is normal.
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d. Mean arterial pressure (MAP) is 72 mm Hg.
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ANSWER
ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that f
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luid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining th
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e effects of fluid administration, but they are not as useful as data indicating good organ perfusion.
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QUESTION 7 vc
10. Which intervention will the nurse include in the plan of care for a patient who has ca
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rdiogenic shock? vc
a. Check temperature every 2 hours.
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b. Monitor breath sounds frequently.
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c. Maintain patient in supine position.
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d. Assess skin for flushing and itching.
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ANSWER
ANS: B Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse sho
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uld assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in
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patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical
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of cardiogenic shock.
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QUESTION 8 vc
12. A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to t
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reat cardiogenic shock. Which finding indicates that the medication is effective?
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a. No new heart murmurs
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b. Decreased troponin level
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c. Warm, pink, and dry skin
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d. Blood pressure 92/40 mm Hg
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ANSWER
ANS: C Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a
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vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murm
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ur and a decrease in troponin level are not indicators of improvement in shock.
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, QUESTION 9 vc
13. Which assessment information is most important for the nurse to obtain to evaluate
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whether treatment of a patient with anaphylactic shock has been effective?
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a. Heart rate
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b. Orientation
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c. Blood pressure
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d. Oxygen saturation
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ANSWER
ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, t
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he oxygen saturation is the most critical assessment. Improvements in the other assessments will also b
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e expected with effective treatment of anaphylactic shock.
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QUESTION 10 vc
17. The nurse is caring for a patient who has septic shock. Which assessment finding is m
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ost important for the nurse to report to the health care provider?
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a. Blood pressure (BP) 92/56 mm Hg
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b. Skin cool and clammy
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c. Oxygen saturation 92%
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d. Heart rate 118 beats/minute
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ANSWER
ANS: B Because patients in the early stage of septic shock have warm and dry skin, the patients cool and
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clammy skin indicates that shock is progressing. The other information will also be reported, but does
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not indicate deterioration of the patients status.
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QUESTION 11 vc
18. A patient is admitted to the emergency department (ED) for shock of unknown etiolo
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gy. The first action by the nurse should be to
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a. administer oxygen.
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b. obtain a 12-lead electrocardiogram (ECG).
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c. obtain the blood pressure.
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d. check the level of consciousness.
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ANSWER
ANS: A The initial actions of the nurse are focused on the ABCsairway, breathing, and circulationand ad
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ministration of oxygen should be done first. The other actions should be accomplished as rapidly as pos
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sible after oxygen administration.
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QUESTION 12 vc
Exam Solution vc
Shock Sepsis and Multiple Organ Dysfunction Syndrom vc vc vc vc vc vc
e 2026 A+ GRADE ASSURED COMPLETE SOLUTIONS AN
vc vc vc vc vc vc vc
D VERIFIED ANSWERS (D0ED0)
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QUESTION 1 vc
3. A 19-year-
vc vc
old patient with massive trauma and possible spinal cord injury is admitted to the emerg
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ency department (ED). Which assessment finding by the nurse will help confirm a diagno
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sis of neurogenic shock?
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a. Inspiratory crackles.
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b. Cool, clammy extremities.
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c. Apical heart rate 45 beats/min.
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d. Temperature 101.2 F (38.4 C).
vc vc vc vc vc
ANSWER
ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
more consistent with other types of shock.
vc vc vc vc vc vc
QUESTION 2 vc
5. After receiving 2 L of normal saline, the central venous pressure for a patient who has
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will an
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ticipate an order for vc vc vc
a. nitroglycerine (Tridil).
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b. norepinephrine (Levophed).
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c. sodium nitroprusside (Nipride).
vc vc vc
d. methylprednisolone (Solu-Medrol).
vc vc
ANSWER
ANS: B When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the syst
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
emic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would d
vc vc vc vc vc vc vc vc vc vc vc vc vc
ecrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-
vc vc vc vc vc vc vc vc vc vc vc
Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
is an arterial vasodilator and would further decrease SVR. Normal CVP is between 2-
vc vc vc vc vc vc vc vc vc vc vc vc vc
6. In septic shock, first give fluids, then vasopressors, then steroids.
vc vc vc vc vc vc vc vc vc vc
,QUESTION 3 vc
6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with
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systemic inflammatory response syndrome (SIRS), which assessment will the nurse perf
vc vc vc vc vc vc vc vc vc vc vc
orm?
a. Auscultate bowel sounds.
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b. Palpate for abdominal pain.
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c. Ask the patient about nausea.
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d. Check stools for occult blood.
vc vc vc vc vc
ANSWER
ANS: D Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. T
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
he other assessments also will be done, but these will not help in determining the effectiveness of the p
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antoprazole administration. vc
QUESTION 4 vc
7. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, r
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espirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac o
vc vc vc vc vc vc vc vc vc vc vc vc
utput is low. The nurse will anticipate an order for which medication?
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a. 5% human albumin
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b. Furosemide (Lasix) IV
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c. Epinephrine (Adrenalin) drip
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d. Hydrocortisone (Solu-Cortef)
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ANSWER
ANS: B The PAWP indicates that the patients preload is elevated, and furosemide is indicated to reduce
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considere
vc vc vc vc vc vc vc vc vc vc vc vc vc
d for septic or anaphylactic shock.
vc vc vc vc vc
QUESTION 5 vc
8. The emergency department (ED) nurse receives report that a patient involved in a mo
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
tor vehicle crash is being transported to the facility with an estimated arrival in 1 minut
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
e. In preparation for the patients arrival, the nurse will obtain
vc vc vc vc vc vc vc vc vc vc
a. hypothermia blanket.
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b. lactated Ringers solution.
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c. two 14-gauge IV catheters.
vc vc vc vc
d. dopamine (Intropin) infusion.
vc vc vc
ANSWER
ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic s
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
hock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactate
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
d Ringers solution should be used cautiously and will not be ordered until the patient has been assessed
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
, for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
shock. Patients in shock need to be kept warm not cool.
vc vc vc vc vc vc vc vc vc vc
QUESTION 6 vc
9. Which finding is the best indicator that the fluid resuscitation for a patient with hypov
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olemic shock has been effective? vc vc vc vc
a. Hemoglobin is within normal limits.
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b. Urine output is 60 mL over the last hour.
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c. Central venous pressure (CVP) is normal.
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d. Mean arterial pressure (MAP) is 72 mm Hg.
vc vc vc vc vc vc vc vc
ANSWER
ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that f
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
luid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining th
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
e effects of fluid administration, but they are not as useful as data indicating good organ perfusion.
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
QUESTION 7 vc
10. Which intervention will the nurse include in the plan of care for a patient who has ca
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
rdiogenic shock? vc
a. Check temperature every 2 hours.
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b. Monitor breath sounds frequently.
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c. Maintain patient in supine position.
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d. Assess skin for flushing and itching.
vc vc vc vc vc vc
ANSWER
ANS: B Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse sho
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
uld assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
of cardiogenic shock.
vc vc
QUESTION 8 vc
12. A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to t
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
reat cardiogenic shock. Which finding indicates that the medication is effective?
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a. No new heart murmurs
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b. Decreased troponin level
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c. Warm, pink, and dry skin
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d. Blood pressure 92/40 mm Hg
vc vc vc vc vc
ANSWER
ANS: C Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc v
vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murm
c vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ur and a decrease in troponin level are not indicators of improvement in shock.
vc vc vc vc vc vc vc vc vc vc vc vc vc
, QUESTION 9 vc
13. Which assessment information is most important for the nurse to obtain to evaluate
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
whether treatment of a patient with anaphylactic shock has been effective?
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a. Heart rate
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b. Orientation
vc
c. Blood pressure
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d. Oxygen saturation
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ANSWER
ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, t
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
he oxygen saturation is the most critical assessment. Improvements in the other assessments will also b
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
e expected with effective treatment of anaphylactic shock.
vc vc vc vc vc vc vc
QUESTION 10 vc
17. The nurse is caring for a patient who has septic shock. Which assessment finding is m
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ost important for the nurse to report to the health care provider?
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a. Blood pressure (BP) 92/56 mm Hg
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b. Skin cool and clammy
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c. Oxygen saturation 92%
vc vc vc
d. Heart rate 118 beats/minute
vc vc vc vc
ANSWER
ANS: B Because patients in the early stage of septic shock have warm and dry skin, the patients cool and
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
clammy skin indicates that shock is progressing. The other information will also be reported, but does
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
not indicate deterioration of the patients status.
vc vc vc vc vc vc
QUESTION 11 vc
18. A patient is admitted to the emergency department (ED) for shock of unknown etiolo
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
gy. The first action by the nurse should be to
vc vc vc vc vc vc vc vc vc
a. administer oxygen.
vc vc
b. obtain a 12-lead electrocardiogram (ECG).
vc vc vc vc vc
c. obtain the blood pressure.
vc vc vc vc
d. check the level of consciousness.
vc vc vc vc vc
ANSWER
ANS: A The initial actions of the nurse are focused on the ABCsairway, breathing, and circulationand ad
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ministration of oxygen should be done first. The other actions should be accomplished as rapidly as pos
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sible after oxygen administration.
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QUESTION 12 vc
