, NUR 265 Exam 4 – Medical-Surgical Nursing - Actual Questions &
Answers (GCN) 100% Guarantee Pass
Question 1
A client is admitted with hypovolemic shock secondary to gastrointestinal bleeding. Which
assessment finding indicates the client is in the compensatory stage of shock?
A) Blood pressure 90/60 mmHg
B) Heart rate 110 bpm
C) Urine output 20 mL/hr
D) Cool, clammy skin
Answer: B
Rationale: In the compensatory stage of shock, the body attempts to maintain perfusion
through sympathetic nervous system activation. Tachycardia (heart rate > 100 bpm) is an early
compensatory response. Hypotension, decreased urine output (< 30 mL/hr), and cool, clammy
skin indicate progressive or decompensated shock.
Question 2
A client with septic shock has a central venous pressure (CVP) of 2 mmHg. The nurse anticipates
which intervention?
A) Administer diuretics
B) Administer IV fluid bolus
C) Start vasopressors
D) Restrict fluids
Answer: B
Rationale: Normal CVP is 2-8 mmHg. A CVP of 2 mmHg indicates low intravascular volume
(hypovolemia). The priority intervention is to administer IV fluid boluses to restore intravascular
volume. Vasopressors are used after fluid resuscitation if hypotension persists.
Question 3
A client with cardiogenic shock is receiving a dobutamine infusion. The nurse should monitor
the client for which therapeutic effect?
A) Decreased heart rate
B) Increased cardiac output
,C) Decreased blood pressure
D) Vasoconstriction
Answer: B
Rationale: Dobutamine is a beta-1 agonist that increases cardiac contractility, thereby
increasing cardiac output and stroke volume. It causes vasodilation (decreased afterload) and
may slightly increase heart rate.
Question 4
Which finding is the EARLIEST indicator of shock in a client with a myocardial infarction?
A) Hypotension
B) Tachycardia
C) Decreased urine output
D) Confusion
Answer: B
Rationale: Tachycardia is often the earliest sign of shock as the body attempts to compensate
for decreased cardiac output. Hypotension, decreased urine output, and confusion are later
signs of progressive shock.
Question 5
A client in septic shock has a lactate level of 4.5 mmol/L. The nurse interprets this finding as:
A) Normal finding
B) Indication of tissue hypoperfusion
C) Indication of liver dysfunction
D) Indication of fluid overload
Answer: B
Rationale: Normal serum lactate is < 2 mmol/L. Elevated lactate (> 4 mmol/L) indicates tissue
hypoperfusion and anaerobic metabolism, which is a hallmark of septic shock. This finding
requires immediate intervention (fluid resuscitation, antibiotics, vasopressors).
, Question 6
A client with neurogenic shock following a spinal cord injury at T6. Which finding is most
characteristic?
A) Hypertension and bradycardia
B) Hypotension and bradycardia
C) Hypertension and tachycardia
D) Hypotension and tachycardia
Answer: B
Rationale: Neurogenic shock is characterized by hypotension and bradycardia due to loss of
sympathetic tone (vasodilation) from spinal cord injury above T6. The patient may also have
poikilothermia (inability to regulate temperature).
Question 7
A client with anaphylactic shock is receiving epinephrine. Which finding indicates the
medication is effective?
A) Decreased heart rate
B) Increased blood pressure
C) Decreased respiratory rate
D) Vasodilation
Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylactic shock. Therapeutic effects
include increased blood pressure (vasoconstriction), bronchodilation (improved oxygenation),
and decreased edema. Increased heart rate is also expected.
Question 8
A client with septic shock is receiving norepinephrine (Levophed). The nurse should monitor for
which adverse effect?
A) Hypotension
B) Bradycardia
C) Tissue ischemia
D) Diarrhea
Answer: C
Answers (GCN) 100% Guarantee Pass
Question 1
A client is admitted with hypovolemic shock secondary to gastrointestinal bleeding. Which
assessment finding indicates the client is in the compensatory stage of shock?
A) Blood pressure 90/60 mmHg
B) Heart rate 110 bpm
C) Urine output 20 mL/hr
D) Cool, clammy skin
Answer: B
Rationale: In the compensatory stage of shock, the body attempts to maintain perfusion
through sympathetic nervous system activation. Tachycardia (heart rate > 100 bpm) is an early
compensatory response. Hypotension, decreased urine output (< 30 mL/hr), and cool, clammy
skin indicate progressive or decompensated shock.
Question 2
A client with septic shock has a central venous pressure (CVP) of 2 mmHg. The nurse anticipates
which intervention?
A) Administer diuretics
B) Administer IV fluid bolus
C) Start vasopressors
D) Restrict fluids
Answer: B
Rationale: Normal CVP is 2-8 mmHg. A CVP of 2 mmHg indicates low intravascular volume
(hypovolemia). The priority intervention is to administer IV fluid boluses to restore intravascular
volume. Vasopressors are used after fluid resuscitation if hypotension persists.
Question 3
A client with cardiogenic shock is receiving a dobutamine infusion. The nurse should monitor
the client for which therapeutic effect?
A) Decreased heart rate
B) Increased cardiac output
,C) Decreased blood pressure
D) Vasoconstriction
Answer: B
Rationale: Dobutamine is a beta-1 agonist that increases cardiac contractility, thereby
increasing cardiac output and stroke volume. It causes vasodilation (decreased afterload) and
may slightly increase heart rate.
Question 4
Which finding is the EARLIEST indicator of shock in a client with a myocardial infarction?
A) Hypotension
B) Tachycardia
C) Decreased urine output
D) Confusion
Answer: B
Rationale: Tachycardia is often the earliest sign of shock as the body attempts to compensate
for decreased cardiac output. Hypotension, decreased urine output, and confusion are later
signs of progressive shock.
Question 5
A client in septic shock has a lactate level of 4.5 mmol/L. The nurse interprets this finding as:
A) Normal finding
B) Indication of tissue hypoperfusion
C) Indication of liver dysfunction
D) Indication of fluid overload
Answer: B
Rationale: Normal serum lactate is < 2 mmol/L. Elevated lactate (> 4 mmol/L) indicates tissue
hypoperfusion and anaerobic metabolism, which is a hallmark of septic shock. This finding
requires immediate intervention (fluid resuscitation, antibiotics, vasopressors).
, Question 6
A client with neurogenic shock following a spinal cord injury at T6. Which finding is most
characteristic?
A) Hypertension and bradycardia
B) Hypotension and bradycardia
C) Hypertension and tachycardia
D) Hypotension and tachycardia
Answer: B
Rationale: Neurogenic shock is characterized by hypotension and bradycardia due to loss of
sympathetic tone (vasodilation) from spinal cord injury above T6. The patient may also have
poikilothermia (inability to regulate temperature).
Question 7
A client with anaphylactic shock is receiving epinephrine. Which finding indicates the
medication is effective?
A) Decreased heart rate
B) Increased blood pressure
C) Decreased respiratory rate
D) Vasodilation
Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylactic shock. Therapeutic effects
include increased blood pressure (vasoconstriction), bronchodilation (improved oxygenation),
and decreased edema. Increased heart rate is also expected.
Question 8
A client with septic shock is receiving norepinephrine (Levophed). The nurse should monitor for
which adverse effect?
A) Hypotension
B) Bradycardia
C) Tissue ischemia
D) Diarrhea
Answer: C
