MDC4 Questions with 100% Correct Answers
The client has decreased volume in the blood vessels, low BP, and high HR what IV
fluids would you anticipate on giving?
isotonic, lactated ringers
Which assessment finding is most consistent with neurogenic shock?
bradycardia, hypotension
Client receiving IV fluids and the blood pressure is still hypotensive. What medication
would you anticipate on giving?
norepinephrine
A client in shock is prescribed a continuous infusion of a vasoactive medication. which
nursing intervention is most important when administering this drug?
place the infusion via central venous catheter
titrate the map to 65
taper down once vitals are within normal limits
what is considered an early intervention for shock?
IV fluids, 30 mL/kg
What is an adverse effect of norepinephrine?
peripheral ischemia
The nurse is caring for a client admitted with cardiogenic shock. The client is
experiencing chest pain, and there is an order for the administration of morphine. In
addition to pain control, what is the main rationale for administering morphine to this
client?
,It dilates the blood vessels.
chest pain
A client in the hospital presents with a narrow pulse pressure, cool and pale skin, and
decreased urine output. The nurse recognizes these signs that the client's shock is
progressing. Which of the following best explains why these symptoms occur?
The sympathetic nervous system is activated, shunting blood to vital organs and away from
the skin and kidneys
A client is admitted with hypovolemic shock secondary to a gastrointestinal bleed.
Which of the following interventions should the nurse anticipate to restore circulating
volume?
Initiate blood transfusion as prescribed
A client develops hypovolemic shock due to severe diarrhea. Which of the following is
the priority intervention?
Initiate intravenous fluid replacement as prescribed
A client's vitals show hypotension, tachycardia, rapid shallow respirations, cool mottled
skin, and confusion. Urine output is markedly decreased. Which stage of shock does this
indicate?
Progressive
A client in shock is unconscious, BP is unresponsive to fluids, heart rate is weak and
irregular, respirations are irregular, and skin is cold and cyanotic. What is the nurse's
priority understanding?
The client is in refractory shock; multi-organ failure is occurring.
, A client is in the irreversible stage of shock and is diagnosed with multiple organ
dysfunction syndrome (MODS). Which of the following assessment findings would the
nurse expect to see?
oliguria, elevated liver enzymes, cool extremities, and absent bowel sounds
A client is brought to the emergency department after a suspected tricyclic
antidepressant (TCA) overdose. which of the following interventions should the nurse
anticipate?
Administer sodium bicarbonate as prescribed and assess airway, cardiac monitoring
A client was admitted to the emergency department with a suspected morphine
overdose. The client is somnolent with pinpoint pupils, a respiratory rate of 8/min, and
oxygen saturation of 88%. Which action should the nurse anticipate as the priority
intervention?
Start an IV line and administer naloxone
A client presents with a headache and confusion after a suspected carbon monoxide
exposure from a water heater at home. Which intervention should the nurse anticipate?
Administer 100% oxygen, remove the client from the source, and consider hyperbaric oxygen
therapy
A client presents after ingesting a large amount of a strong acid. Gastric lavage was
attempted but was not effective, and several hours have passed since ingestion. Which
intervention might the nurse anticipate to help neutralize the acid?
encourage the client to drink milk or small amounts of water
The client has decreased volume in the blood vessels, low BP, and high HR what IV
fluids would you anticipate on giving?
isotonic, lactated ringers
Which assessment finding is most consistent with neurogenic shock?
bradycardia, hypotension
Client receiving IV fluids and the blood pressure is still hypotensive. What medication
would you anticipate on giving?
norepinephrine
A client in shock is prescribed a continuous infusion of a vasoactive medication. which
nursing intervention is most important when administering this drug?
place the infusion via central venous catheter
titrate the map to 65
taper down once vitals are within normal limits
what is considered an early intervention for shock?
IV fluids, 30 mL/kg
What is an adverse effect of norepinephrine?
peripheral ischemia
The nurse is caring for a client admitted with cardiogenic shock. The client is
experiencing chest pain, and there is an order for the administration of morphine. In
addition to pain control, what is the main rationale for administering morphine to this
client?
,It dilates the blood vessels.
chest pain
A client in the hospital presents with a narrow pulse pressure, cool and pale skin, and
decreased urine output. The nurse recognizes these signs that the client's shock is
progressing. Which of the following best explains why these symptoms occur?
The sympathetic nervous system is activated, shunting blood to vital organs and away from
the skin and kidneys
A client is admitted with hypovolemic shock secondary to a gastrointestinal bleed.
Which of the following interventions should the nurse anticipate to restore circulating
volume?
Initiate blood transfusion as prescribed
A client develops hypovolemic shock due to severe diarrhea. Which of the following is
the priority intervention?
Initiate intravenous fluid replacement as prescribed
A client's vitals show hypotension, tachycardia, rapid shallow respirations, cool mottled
skin, and confusion. Urine output is markedly decreased. Which stage of shock does this
indicate?
Progressive
A client in shock is unconscious, BP is unresponsive to fluids, heart rate is weak and
irregular, respirations are irregular, and skin is cold and cyanotic. What is the nurse's
priority understanding?
The client is in refractory shock; multi-organ failure is occurring.
, A client is in the irreversible stage of shock and is diagnosed with multiple organ
dysfunction syndrome (MODS). Which of the following assessment findings would the
nurse expect to see?
oliguria, elevated liver enzymes, cool extremities, and absent bowel sounds
A client is brought to the emergency department after a suspected tricyclic
antidepressant (TCA) overdose. which of the following interventions should the nurse
anticipate?
Administer sodium bicarbonate as prescribed and assess airway, cardiac monitoring
A client was admitted to the emergency department with a suspected morphine
overdose. The client is somnolent with pinpoint pupils, a respiratory rate of 8/min, and
oxygen saturation of 88%. Which action should the nurse anticipate as the priority
intervention?
Start an IV line and administer naloxone
A client presents with a headache and confusion after a suspected carbon monoxide
exposure from a water heater at home. Which intervention should the nurse anticipate?
Administer 100% oxygen, remove the client from the source, and consider hyperbaric oxygen
therapy
A client presents after ingesting a large amount of a strong acid. Gastric lavage was
attempted but was not effective, and several hours have passed since ingestion. Which
intervention might the nurse anticipate to help neutralize the acid?
encourage the client to drink milk or small amounts of water
