Chapter 34: Critical Care of Patients with
Shock
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client is receiving norepinephrine for shock. What assessment finding best indicates
a therapeutic effect from this drug?
a. Alert and oriented, answering questions
b. Client denies chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
ANS: A
Normal cognitive function is a good indicator that the client is receiving the benefits
of norepinephrine. The brain is very sensitive to changes in oxygenation and
perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence
of chest pain is good but does not indicate therapeutic effect. The IV site is normal.
The urine output is normal, but only minimally so.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation
KEY: Shock, Vasoconstrictors MSC: Client Needs Category:
Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse is caring for a client who has a diagnosis of multiple organ dysfunction
syndrome (MODS) who will be receiving sodium nitroprusside via IV infusion. What
action by the nurse causes the charge nurse to intervene?
a. Assessing the IV site before giving the drug
, b. Obtaining a programmable (“smart”) IV pump
c. Removing the IV bag from the brown plastic cover
d. Taking and recording a baseline set of vital signs
ANS: C
Nitroprusside degrades in the presence of light, so it must be protected by leaving it in
the original brown plastic bag when infusing. The other actions are correct
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Shock, Vasoconstrictors MSC: Client Needs Category:
Physiological Integrity: Pharmacological and Parenteral Therapies
3. A nurse on the general medical-surgical unit is caring for a client in shock and
assesses the following:
Respiratory rate: 10 breaths/min
Pulse: 136 beats/min
Blood pressure: 92/78 mm Hg
Level of consciousness: responds to voice
Temperature: 101.5° F (38.5° C)
Urine output for the last 2 hours: 40 mL/hr.
What action by the nurse is best?
a. Transfer the client to the Intensive Care Unit.
b. Continue monitoring every 30 minutes.
c. Notify the unit charge nurse immediately.
d. Call the Rapid Response Team.
ANS: D
This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1,
UO: 1). Scores above 5 are associated with a high risk of death and ICU admission.
Shock
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client is receiving norepinephrine for shock. What assessment finding best indicates
a therapeutic effect from this drug?
a. Alert and oriented, answering questions
b. Client denies chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
ANS: A
Normal cognitive function is a good indicator that the client is receiving the benefits
of norepinephrine. The brain is very sensitive to changes in oxygenation and
perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence
of chest pain is good but does not indicate therapeutic effect. The IV site is normal.
The urine output is normal, but only minimally so.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation
KEY: Shock, Vasoconstrictors MSC: Client Needs Category:
Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse is caring for a client who has a diagnosis of multiple organ dysfunction
syndrome (MODS) who will be receiving sodium nitroprusside via IV infusion. What
action by the nurse causes the charge nurse to intervene?
a. Assessing the IV site before giving the drug
, b. Obtaining a programmable (“smart”) IV pump
c. Removing the IV bag from the brown plastic cover
d. Taking and recording a baseline set of vital signs
ANS: C
Nitroprusside degrades in the presence of light, so it must be protected by leaving it in
the original brown plastic bag when infusing. The other actions are correct
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Shock, Vasoconstrictors MSC: Client Needs Category:
Physiological Integrity: Pharmacological and Parenteral Therapies
3. A nurse on the general medical-surgical unit is caring for a client in shock and
assesses the following:
Respiratory rate: 10 breaths/min
Pulse: 136 beats/min
Blood pressure: 92/78 mm Hg
Level of consciousness: responds to voice
Temperature: 101.5° F (38.5° C)
Urine output for the last 2 hours: 40 mL/hr.
What action by the nurse is best?
a. Transfer the client to the Intensive Care Unit.
b. Continue monitoring every 30 minutes.
c. Notify the unit charge nurse immediately.
d. Call the Rapid Response Team.
ANS: D
This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1,
UO: 1). Scores above 5 are associated with a high risk of death and ICU admission.
