MULTI-SYSTEM (SHOCK AND PERFUSION)
EXAM- PHT2162-2024| ACTUAL QUIZ
WITH CORRECT DETAILED ANSWERS
The nurse is caring for a client admitted with shock secondary to severe gastrointestinal bleeding. Once the
client is stabilized, what intervention should the nurse do next?
1 Monitor the peripheral pulses.
2 Check the level of consciousness.
Correct3 Take a blood sample for laboratory tests.
4 Control the bleeding with a pressure dressing.
The primary nursing intervention that should be followed in the client’s condition with gastrointestinal
bleeding is collection of a blood sample for laboratory diagnosis. Peripheral pulses are monitored in an
ongoing manner. Level of consciousness may not be required to be monitored based on the client’s condition.
Controlling bleeding with a pressure dressing is usually done in case of deep lacerations and wounds.
A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical
indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all
that apply.
11Spasticity
2Incontinence
Correct3 Flaccid paralysis
4 Respiratory failure
Correct5 Lack of reflexes below the injury
Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid
paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock
is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury.
Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as
a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but
spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not
affected.
A female client who is receiving intravenous antibiotic therapy at home for treatment of toxic shock syndrome
is visited by a home health nurse. What statement indicates to the nurse that the client understands the teaching
regarding future care?
, Correct1 "I will call the clinic if I get a rash."
2 "I will call the clinic if the menstrual cramps return."
3 "I now know how to insert my diaphragm correctly."
4 "I now know how to perform correct tampon hygiene."
Toxic shock syndrome may recur during the first 3 months after treatment; a sunburn-like rash with peeling
skin often occurs in the late stages of the syndrome. There is no need for the client to call the clinic if
menstrual cramps return, because this is not specifically related to toxic shock syndrome. Whether the
diaphragm is inserted properly is not the issue; it is linked to toxic shock syndrome if it is not removed 6 to 8
hours after intercourse. Tampons are linked to the development of toxic shock syndrome and should not be
worn by this client.
,A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do
when caring for this client?
Correct1 Encourage range of motion to the client's arm on the affected side
2 Administer the prescribed cough suppressant at the prescribed times
3 Empty and measure the drainage in the collection chamber each shift
4 Apply clamps below the insertion site when getting the client out of bed
Range-of-motion exercises to the client's arm on the affected side promote maintenance of function in the
arm and shoulder. Cough suppressants are not indicated because coughing and deep breathing are encouraged
to help re-expand the lung. Drainage is marked with time taped on the side of the device. The closed system is
not entered for emptying; when full, the entire device is replaced. Clamps are not necessary and should be
avoided because of the danger of precipitating a tension pneumothorax.
A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The
client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse
explain the function of the water?
1 Promotes pleural drainage via gravity
2 Measures the pressures in the chest wall
Correct3 Prevents reflux of air back into the chest
4 Ensures bubbling in the water-seal chamber
Water acts as a seal, preventing air from entering the pleural space, which will interfere with expansion of the
lung. Removal of air (drainage) is promoted by negative pressure, not gravity, in the closed chest drainage
system. Water in the system does not facilitate measurement of pressures in the chest wall; this is not the
purpose of a water-seal drainage system. Although air exiting the pleural space will cause bubbling in the
water-seal chamber, water in the system does not ensure bubbling in the water-seal chamber; this is not the
purpose of the water-seal chamber.
While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is
the nurse's immediate action?
1 Place the client in the supine position
2 Spread a clamp in the insertion site to hold the site open
3 Obtain a sterile Vaseline gauze to cover the opening
Correct4 Cover the opening with the cleanest material available
This emergency situation requires covering the opening with the cleanest material available to prevent
atmospheric air from entering the thoracic cavity; the client's respiratory status takes priority over the potential
for infection. Placing the client in the supine position is useless and will impair further the client's breathing.
Using a clamp to hold the insertion site open is unsafe because it allows atmospheric air to enter the thoracic
cavity. Although an occlusive dressing is desirable, atmospheric air will enter the thoracic cavity while time is
taken to obtain the occlusive dressing.
A client who sustained serious burns now has a stress ulcer. Which clinical indicators of shock should the nurse
immediately report to the primary healthcare provider? Select all that apply.
Correct1 Weakness
Correct2 Diaphoresis
, Correct3 Tachycardia
Correct4 Cold extremities
5 Flushed skin tone
The stress ulcer can bleed, leading to shock. Weakness is related to the decrease in the oxygen-carrying
capacity of the blood associated with shock. Diaphoresis and tachycardia are sympathetic nervous system
responses associated with shock. Peripheral vasoconstriction is associated with the sympathetic nervous system
response associated with shock and leads to cold extremities. The skin will be pale, rather than flushed,
because of peripheral vasoconstriction.
A client is in profound (late) hypovolemic shock. The nurse assesses the client’s laboratory values. What
does the nurse know that clients in late shock develop?
1 Hypokalemia
Correct2 Metabolic acidosis
3 Respiratory alkalosis
4 Decreased Pco2 levels
Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis.
Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory
alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or
respiratory acidosis occurs. The Pco2 level will increase in profound shock.
The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic
shock. Which clinical manifestations support these diagnoses? Select all that apply.
Correct1 Rapid pulse
2 Deep respirations
3 Warm, flushed skin
4 Increased blood pressure
Correct5 Decreased urinary output
The heart rate increases (tachycardia) in an attempt to meet the body’s oxygen demands and circulate blood
to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output
decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system
increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold
and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is
decreased, not increased, because of continued hypoperfusion and multiorgan failure.
A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The
nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.
Correct1 Bradycardia
Correct2 Hypotension
3 Spastic paralysis
Correct4 Bladder dysfunction
5 Increased pulse pressure
Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the
cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in
EXAM- PHT2162-2024| ACTUAL QUIZ
WITH CORRECT DETAILED ANSWERS
The nurse is caring for a client admitted with shock secondary to severe gastrointestinal bleeding. Once the
client is stabilized, what intervention should the nurse do next?
1 Monitor the peripheral pulses.
2 Check the level of consciousness.
Correct3 Take a blood sample for laboratory tests.
4 Control the bleeding with a pressure dressing.
The primary nursing intervention that should be followed in the client’s condition with gastrointestinal
bleeding is collection of a blood sample for laboratory diagnosis. Peripheral pulses are monitored in an
ongoing manner. Level of consciousness may not be required to be monitored based on the client’s condition.
Controlling bleeding with a pressure dressing is usually done in case of deep lacerations and wounds.
A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical
indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all
that apply.
11Spasticity
2Incontinence
Correct3 Flaccid paralysis
4 Respiratory failure
Correct5 Lack of reflexes below the injury
Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid
paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock
is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury.
Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as
a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but
spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not
affected.
A female client who is receiving intravenous antibiotic therapy at home for treatment of toxic shock syndrome
is visited by a home health nurse. What statement indicates to the nurse that the client understands the teaching
regarding future care?
, Correct1 "I will call the clinic if I get a rash."
2 "I will call the clinic if the menstrual cramps return."
3 "I now know how to insert my diaphragm correctly."
4 "I now know how to perform correct tampon hygiene."
Toxic shock syndrome may recur during the first 3 months after treatment; a sunburn-like rash with peeling
skin often occurs in the late stages of the syndrome. There is no need for the client to call the clinic if
menstrual cramps return, because this is not specifically related to toxic shock syndrome. Whether the
diaphragm is inserted properly is not the issue; it is linked to toxic shock syndrome if it is not removed 6 to 8
hours after intercourse. Tampons are linked to the development of toxic shock syndrome and should not be
worn by this client.
,A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do
when caring for this client?
Correct1 Encourage range of motion to the client's arm on the affected side
2 Administer the prescribed cough suppressant at the prescribed times
3 Empty and measure the drainage in the collection chamber each shift
4 Apply clamps below the insertion site when getting the client out of bed
Range-of-motion exercises to the client's arm on the affected side promote maintenance of function in the
arm and shoulder. Cough suppressants are not indicated because coughing and deep breathing are encouraged
to help re-expand the lung. Drainage is marked with time taped on the side of the device. The closed system is
not entered for emptying; when full, the entire device is replaced. Clamps are not necessary and should be
avoided because of the danger of precipitating a tension pneumothorax.
A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The
client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse
explain the function of the water?
1 Promotes pleural drainage via gravity
2 Measures the pressures in the chest wall
Correct3 Prevents reflux of air back into the chest
4 Ensures bubbling in the water-seal chamber
Water acts as a seal, preventing air from entering the pleural space, which will interfere with expansion of the
lung. Removal of air (drainage) is promoted by negative pressure, not gravity, in the closed chest drainage
system. Water in the system does not facilitate measurement of pressures in the chest wall; this is not the
purpose of a water-seal drainage system. Although air exiting the pleural space will cause bubbling in the
water-seal chamber, water in the system does not ensure bubbling in the water-seal chamber; this is not the
purpose of the water-seal chamber.
While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is
the nurse's immediate action?
1 Place the client in the supine position
2 Spread a clamp in the insertion site to hold the site open
3 Obtain a sterile Vaseline gauze to cover the opening
Correct4 Cover the opening with the cleanest material available
This emergency situation requires covering the opening with the cleanest material available to prevent
atmospheric air from entering the thoracic cavity; the client's respiratory status takes priority over the potential
for infection. Placing the client in the supine position is useless and will impair further the client's breathing.
Using a clamp to hold the insertion site open is unsafe because it allows atmospheric air to enter the thoracic
cavity. Although an occlusive dressing is desirable, atmospheric air will enter the thoracic cavity while time is
taken to obtain the occlusive dressing.
A client who sustained serious burns now has a stress ulcer. Which clinical indicators of shock should the nurse
immediately report to the primary healthcare provider? Select all that apply.
Correct1 Weakness
Correct2 Diaphoresis
, Correct3 Tachycardia
Correct4 Cold extremities
5 Flushed skin tone
The stress ulcer can bleed, leading to shock. Weakness is related to the decrease in the oxygen-carrying
capacity of the blood associated with shock. Diaphoresis and tachycardia are sympathetic nervous system
responses associated with shock. Peripheral vasoconstriction is associated with the sympathetic nervous system
response associated with shock and leads to cold extremities. The skin will be pale, rather than flushed,
because of peripheral vasoconstriction.
A client is in profound (late) hypovolemic shock. The nurse assesses the client’s laboratory values. What
does the nurse know that clients in late shock develop?
1 Hypokalemia
Correct2 Metabolic acidosis
3 Respiratory alkalosis
4 Decreased Pco2 levels
Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis.
Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory
alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or
respiratory acidosis occurs. The Pco2 level will increase in profound shock.
The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic
shock. Which clinical manifestations support these diagnoses? Select all that apply.
Correct1 Rapid pulse
2 Deep respirations
3 Warm, flushed skin
4 Increased blood pressure
Correct5 Decreased urinary output
The heart rate increases (tachycardia) in an attempt to meet the body’s oxygen demands and circulate blood
to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output
decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system
increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold
and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is
decreased, not increased, because of continued hypoperfusion and multiorgan failure.
A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The
nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.
Correct1 Bradycardia
Correct2 Hypotension
3 Spastic paralysis
Correct4 Bladder dysfunction
5 Increased pulse pressure
Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the
cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in
