During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?
a. New onset of confusion
b. Heart rate 112 beats/minute
c. Decreased bowel sounds
d. Pale, cool, and dry extremities
Question 2A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first?
a. Insert two large-bore IV catheters.
b. Initiate continuous electrocardiogram (ECG) monitoring.
c. Provide oxygen at 100 per non-rebreather mask.
d. Draw blood to type and crossmatch for transfusions.
Question 3A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
a. administer oxygen.
b. obtain a 12-lead electrocardiogram (ECG).
c. obtain the blood pressure.
d. check the level of consciousness.
Question 4A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?
a. Give normal saline IV at 500 mL/hr.
b. Give acetaminophen (Tylenol) 650 mg rectally.
c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.
Question 5The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
a. Blood pressure (BP) 92/56 mm Hg
b. Skin cool and clammy
c. Oxygen saturation 92
d. Heart rate 118 beats/minute
Question 6When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?
a. Placing the pulse oximeter on the ear for a patient with septic shock
b. Keeping the head of the bed flat for a patient with hypovolemic shock
c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock
Question 7Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?
a. The patient's serum creatinine level is elevated.
b. The patient complains of intermittent chest pressure.
c. The patient's extremities are cool and pulses are weak.
d. The patient has bilateral crackles throughout lung fields.
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