MSN (Chapter 9. Nursing Care of Patients in
Shock) Questions and Answers
A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements
of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature
98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock? - ✅✅b. Heart
rate 118 beats/min
A patient with gastrointestinal bleeding has hemoglobin of 8.5 g/dL. While receiving care the patient
becomes anxious and irritable and bright red drainage appears through the nasogastric tube. The
patient's vital sign measurements are pulse 130 beats/minute, blood pressure 105/55 mm Hg, and
respirations 28/minute. What should the nurse recognize as causing the changes in the patient's vital
signs? - ✅✅a. Early shock
A patient involved in a motor vehicle accident has pale mucous membranes, diaphoresis, confusion,
blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which finding should the
nurse recognize as the likely cause of acidosis? - ✅✅d. Anaerobic metabolism
A patient with progressive shock is diaphoretic and confused. The most recent blood pressure
measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. Intravenous (IV)
fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output? -
✅✅d. Check urinary catheter for kinking.
A patient with hypovolemic shock is experiencing oliguria due to hemorrhage. Which should the nurse
recognize as the most likely cause of the patient's oliguria? - ✅✅b. Secretion of aldosterone
On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive,
confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the
nurse do first? - ✅✅b. Perform a rapid head-to-toe assessment.
A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160
beats/minute, and respirations 30/minute. The patient is receiving IV fluids at 150 mL/hour, has a blood
transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the
most likely cause of the patient's respiratory rate? - ✅✅b. Inadequate tissue perfusion
, Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical
intervention stops the bleeding, and the shock stabilizes. Which finding should the nurse act upon
immediately? - ✅✅c. Urinary output is 15 mL/hour.
After an episode of shock, a patient's laboratory results reveal elevated serum levels of ammonia and
bilirubin and decreased plasma proteins and clotting factors. Which organ should the nurse recognize as
being damaged from the shock? - ✅✅b. Liver
After an episode of shock, a patient's laboratory results reveal decreased clotting factors. Based on
these laboratory results, the nurse should monitor for which complication of shock? - ✅✅d.
Disseminated intravascular coagulation
The family of a patient in shock asks the nurse to explain the condition. How should the nurse respond
to this family? - ✅✅d. "There is inadequate oxygen delivered to the tissues."
A patient is demonstrating signs of anaphylactic shock. What action should the nurse take first? -
✅✅b. Ensure a patent airway.
The nurse provides comfort measures to maintain normal body temperature and reduce pain and
anxiety for a patient who is experiencing shock. What is the purpose of the nurse performing these
actions? - ✅✅d. Decreases oxygen demand
The nurse is caring for a patient in mild shock. Which medication should the nurse question before
providing if ordered for a patient experiencing shock? - ✅✅b. Morphine
A patient is receiving a dopamine infusion for shock. What should the nurse expect to assess in the
patient because of this medication? - ✅✅c. Increased blood pressure
A patient is admitted with suspected septic shock. Which action should the nurse take first? - ✅✅b.
Insert an IV access device.
Shock) Questions and Answers
A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements
of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature
98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock? - ✅✅b. Heart
rate 118 beats/min
A patient with gastrointestinal bleeding has hemoglobin of 8.5 g/dL. While receiving care the patient
becomes anxious and irritable and bright red drainage appears through the nasogastric tube. The
patient's vital sign measurements are pulse 130 beats/minute, blood pressure 105/55 mm Hg, and
respirations 28/minute. What should the nurse recognize as causing the changes in the patient's vital
signs? - ✅✅a. Early shock
A patient involved in a motor vehicle accident has pale mucous membranes, diaphoresis, confusion,
blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which finding should the
nurse recognize as the likely cause of acidosis? - ✅✅d. Anaerobic metabolism
A patient with progressive shock is diaphoretic and confused. The most recent blood pressure
measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. Intravenous (IV)
fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output? -
✅✅d. Check urinary catheter for kinking.
A patient with hypovolemic shock is experiencing oliguria due to hemorrhage. Which should the nurse
recognize as the most likely cause of the patient's oliguria? - ✅✅b. Secretion of aldosterone
On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive,
confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the
nurse do first? - ✅✅b. Perform a rapid head-to-toe assessment.
A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160
beats/minute, and respirations 30/minute. The patient is receiving IV fluids at 150 mL/hour, has a blood
transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the
most likely cause of the patient's respiratory rate? - ✅✅b. Inadequate tissue perfusion
, Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical
intervention stops the bleeding, and the shock stabilizes. Which finding should the nurse act upon
immediately? - ✅✅c. Urinary output is 15 mL/hour.
After an episode of shock, a patient's laboratory results reveal elevated serum levels of ammonia and
bilirubin and decreased plasma proteins and clotting factors. Which organ should the nurse recognize as
being damaged from the shock? - ✅✅b. Liver
After an episode of shock, a patient's laboratory results reveal decreased clotting factors. Based on
these laboratory results, the nurse should monitor for which complication of shock? - ✅✅d.
Disseminated intravascular coagulation
The family of a patient in shock asks the nurse to explain the condition. How should the nurse respond
to this family? - ✅✅d. "There is inadequate oxygen delivered to the tissues."
A patient is demonstrating signs of anaphylactic shock. What action should the nurse take first? -
✅✅b. Ensure a patent airway.
The nurse provides comfort measures to maintain normal body temperature and reduce pain and
anxiety for a patient who is experiencing shock. What is the purpose of the nurse performing these
actions? - ✅✅d. Decreases oxygen demand
The nurse is caring for a patient in mild shock. Which medication should the nurse question before
providing if ordered for a patient experiencing shock? - ✅✅b. Morphine
A patient is receiving a dopamine infusion for shock. What should the nurse expect to assess in the
patient because of this medication? - ✅✅c. Increased blood pressure
A patient is admitted with suspected septic shock. Which action should the nurse take first? - ✅✅b.
Insert an IV access device.
