NCLEX Review Questions (Wagner) - Chapter (36)

Chapter 36: Shock States NCLEX® Review This activity contains 10 questions. A nurse would assign which nursing diagnosis to any patient diagnosed with shock? Impaired Gas Exchange Imbalanced Nutrition: Less than body requirements Ineffective Airway Clearance Altered Tissue Perfusion A patient's SvO2 measurement is low. This suggests the nurse should provide which intervention? Decrease the patient's nasal oxygen flow. Assess the patient's level of pain and anxiety. Roll the patient from side to side in bed. Offer the patient a carbohydrate-rich liquid supplement to drink. A patient who is in shock will be intubated and placed on mechanical ventilation. How should the nurse explain the benefits of these actions to his family? Select all that apply. "These measures will prevent him from developing ARDS." "These interventions will help us be certain he is maintaining an open airway." "He won't have such a risk for developing pneumonia if he is on a mechanical ventilator." "Putting him on the ventilator will reduce the work he is doing to breathe." "The mechanical ventilator will help us to give him the proper amounts of oxygen." The nurse suspects that a patient may be developing right ventricular failure and cardiogenic shock. The nurse would assess for which supporting findings? Select all that apply. Presence of a third heart sound Split S2 heart sound 3+ edema in lower extremities The patient is dyspneic. Elevated pulmonary artery wedge pressure (PAWP) A patient presents with a 5-day history of nausea, vomiting, diarrhea, and fever. He has not been able to take fluids by mouth. The nurse provides care based on this patient's risk for which problem? Cardiogenic shock Septic shock Obstructive shock Hypovolemic shock An adult patient with hypovolemic shock is given 2 liters of IV fluid. Which outcomes indicate to the nurse that the fluid is having the desired effect? Select all that apply. The patient is normotensive. The patient is alert and oriented. The patient's respiratory rate is 22 breaths per minute. The patient's cardiac monitor reveals sinus rhythm. The patient had 20 mL of urine output over the last hour. A patient presents to the Emergency Department with the report of being stung by a bee. The patient is experiencing dyspnea, edema, and rash. Which medication would the nurse anticipate administering immediately to help prevent progression to anaphylactic shock? Albuterol breathing treatment Prednisone orally Dopamine Epinephrine IM A patient experienced blunt trauma to the chest in a motor vehicle crash that occurred an hour ago. Auscultation of the heart tones reveals them to be muffled. Which assessment findings would support the nurse's concern that the patient may have cardiac tamponade? Select all that apply. Tachycardia Systolic blood pressure is elevated. Tracheal deviation The patient is suddenly dyspneic. Distention of the neck veins A patient is receiving nitroglycerine by IV infusion. The nurse would decrease the flow rate of this drug if which assessment were present? The patient's systolic blood pressure is 90 mmHg. The patient complains of chest pain. The patient's heart rate is 90 bpm. The patient develops a headache. The patient is receiving vasopressin through a peripheral IV site. The nurse notes that the site is running slowly and fluid is leaking from the site. Which actions are indicated? Select all that apply. Slow the infusion rate. Discontinue the infusion site. Readjust the IV catheter. Notify the primary health care provider. Retape the site and reassess in 15 minutes.