Nursing Care

1. A patient who has gastrointestinal bleeding is awake, alert, and oriented. The patient’s vital signs are: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C). Which of this patient’s data collection findings should the nurse consider as a possible sign of early shock? a. Blood pressure 130/90 mm Hg b. Heart rate 118 beats/min c. Respirations 18/min d. Temperature 98.6°F (37°C) 2. A patient with gastrointestinal bleeding has a hemoglobin of 8.5 g/dL. As the nurse assists the patient, who is anxious and irritable, the patient’s nasogastric drainage becomes bright red, pulse 130 beats/minute, blood pressure 105/55 mm Hg, respirations 28/minute. The nurse recognizes which of the following is likely respon- sible for the changes in the patient’s vital signs? a. Early shock b. Patient anxiety c. Progressive shock d. Parasympathetic response 3. Data collection findings for a patient involved in a motor vehicle accident include pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which of these does the nurse recognize as the likely cause of this acidosis? a. Inadequate ventilation b. Hyperventilation c. Aerobic metabolism d. Anaerobic metabolism 4. A patient experiencing progressive shock is diaphoretic, is confused, has a blood pressure of 82/40 mm Hg, and has a urinary catheter output of 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output? a. Irrigate urinary catheter. b. Encourage oral fluids. c. Check urinary catheter for kinking. d. Increase IV fluid infusion rate. 5. The nurse is caring for a patient who has hypovolemic shock and oliguria due to hemorrhage. The nurse rec- ognizes that which of the following is the most likely cause of the patient’s oliguria? a. Inadequate oral fluid intake b. Secretion of aldosterone c. End-stage renal failure d. Obstructed urinary catheter 6. On arrival in the emergency department, a patient who was in a motor vehicle accident is reported to be ap- prehensive, confused, hypotensive, tachycardic, and oliguric, with cool and clammy skin. What should the nurse do first? a. Perform a rapid head-to-toe assessment. b. Obtain patient’s medical history from family. c. Cover patient with warm blankets. d. Reorient the patient to person, place, and time. 7. 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 intravenous fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. Which of the following does the nurse recognize as the most likely cause of the patient’s respiratory rate? a. Electrolyte imbalances b. Inadequate tissue perfusion c. Reaction to the blood transfusion d. Rapid rate of fluid replacement 8. Despite aggressive treatment, the condition of a patient who is in shock continues to worsen. Surgical inter- vention stops the bleeding, and the shock stabilizes. Which of the following findings would require immediate action by the nurse? a. Pupils are equally reactive to light. b. Bowel sounds are hypoactive. c. Urinary output is 15 mL/hour. d. The blood pH is 7.36. 9. 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. The nurse recognizes that these abnormalities indicate damage to which of these organs? a. Heart b. Intestines c. Kidneys d. Liver 10. After an episode of shock, a patient’s laboratory results reveal decreased clotting factors. Based on these labo- ratory results, the nurse monitors for signs of which complication of shock? a. Brain attack b. Disseminated intravascular coagulation c. Multisystem organ failure d. Adult respiratory distress syndrome 11. A patient’s family asks the nurse what shock is. Which of the following statements by the nurse would be most appropriate? a. “It is a profound circulatory collapse.” b. “There is inadequate oxygen delivered to the tissues.” c. “It is the result of overwhelming emotion.” d. “It is caused by massive blood loss.” 12. A patient presents with findings of anaphylactic shock. Which of the following nursing actions is the first pri- ority? a. Provide patient teaching. b. Ensure a patent airway. c. Obtain a detailed patient history. d. Provide pain relief. 13. The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a patient who is experiencing shock. Which of the following benefits do these measures provide? a. Decreased fluid volume b. Increased fluid volume c. Decreased oxygen demand d. Increased oxygen demand 14. The nurse is caring for a patient in mild shock. Which of the following medications should the nurse question if ordered for a patient experiencing shock? a. Benadryl b. Solu-medrol c. Morphine d. Dopamine 15. The patient is started on a dopamine infusion for shock. The nurse would expect to see which of the following findings due to the dopamine? a. Increased respiratory rate b. Increased blood pressure c. Decreased heart rate d. Pain relief 16. A patient presents with suspected septic shock. Which of the following actions should the nurse take first? a. Reassure the patient that everything possible will be done. b. Insert an angiocath. c. Obtain patient temperature. d. Determine if the patient has any medication allergies. 17. A patient who had vascular leg surgery is found standing in a large pool of blood flowing from the surgical site. The patient is assisted into bed and is found to be pale with a palpable pulse. What action should the nurse take? a. Apply oxygen at 2 L/min via nasal cannula. b. Elevate legs and apply pressure over the bleeding site. c. Start an infusion of 0.9% NaCl. d. Notify the registered nurse. 18. A patient who is found hemorrhaging from an incision has a blood pressure of 70/0 mm Hg. What type of fluid replacement does the nurse anticipate will be ordered initially? a. Fresh frozen plasma b. Packed red blood cells c. 0.9 % normal saline d. Lactated Ringer’s with 50 mL albumin 19. The nurse discovers a patient who is experiencing respiratory distress and mild shock. In which of the follow- ing positions should the patient be placed? a. Semi-Fowler’s position b. High Fowler’s position c. Flat with elevated foot of bed d. Trendelenburg position 20. 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 of these orders should the nurse question? a. Electrocardiogram (ECG) STAT b. 500 mL 0.9% NS over 30 minutes c. Arterial blood gases (ABGs) STAT and repeat in 1 hour d. Oxygen 2 L/min via nasal cannula