Nursing 411
What will the nurse identify as symptoms of hypovolemic shock in a patient? (choose all
that apply)
A) Capillary refill time greater than 30 seconds
B) Temperature of 97.6F (36.4C)
C) Decrease in blood pressure of 20 mmHg when the patient sits up
D) Restlessness
E) Sinus bradycardia of 55 beats per minute - answerA) Due to decreased blood flow to
the brain and peripheral areas when blood is shunted to maintain the vital organs,
capillary refill time will be reduced
C) Orthostatic hypotension is a manifestation of hypovolemic shock
D) Due to decreased blood flow to the brain and peripheral areas when blood is shunted
to maintain the vital organs, cerebral hypoxia occurs, leading to change in mental status
Which laboratory finding should cause the nurse to suspect that a patient is developing
hypovolemic shock?
Select one:
A) SvO2 greater than 80%
B) Normal serum lactate of 1 mmol/L
C) Metabolic acidosis validated by arterial blood gases
D) Low serum sodium of 130 mEq/L (130 mmol/L) - answerC) Metabolic acidosis is
present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from
decreased tissue perfusion
The nurse recognizes that which patient would be the most likely to develop
hypovolemic shock? A patient with:
Select one:
A) Sodium retention
B) Decreased cardiac output
C) Severe constipation, causing watery diarrhea
D) Ascites - answerD) Third spacing shifts move the fluids from the intravascular space
into the interstitial space causing a drop in the circulating blood volume. Therefore, third
spacing is a risk factor for the development of hypovolemic shock. Overhydration does
not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic
shock, congestive heart failure, and pulmonary edema.
Which finding indicates that a patient is experiencing increased peripheral resistance
and vasoconstriction?
Select one:
,A) Faster than normal capillary refill times
B) Strong bounding pulse and deep red skin color
C) Pale, cool extremities with decreased pulses
D) Increased venous engorgement with strong pulses - answerC) Increased peripheral
resistance causes the blood supply to decrease and results in decreased blood in the
tissues, which causes pallor and decreased skin temperatures. The pulses would
decrease in intensity with a decreased blood supply.
Which life-threatening complications would the nurse anticipate in the patient being
treated for hypovolemic shock?(choose all that apply)
A) Gastric stress ulcer
B) Pulmonary edema
C) Fluid volume overload
D) Renal insufficiency
E) Cerebral ischemia - answerD) Renal insufficiency is a serious complication because
of the prerenal etiology of hypovolemia,
E) Cerebral ischemia. Early identification and correction of the fluid volume deficit in
hypovolemia shock is necessary to prevent cerebral ischemia.
Which finding indicates that rehydration is complete and hypovolemic shock has been
successfully treated in a patient?
Select one:
A) MAP = 45 mmHg
B) Urinary output of 0.1 mL/kg/hr
C) Hct = 54%
D) CVP = 6 mm HG - answerD) CVP = 6 mm HG. A CVP of 6 mmHg is within normal
range and rehydration has been restored.
A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill.
The nurse suspects the patient is experiencing which type of shock?
Select one:
A) Hypovolemic
B) Obstructive
C) Cardiogenic
D) Anaphylactic - answerC) Cardiogenic. In cardiogenic shock, there is a low cardiac
output, hypotension, and pulmonary edema
A patient is experiencing vasodilation, is diagnosed with distributive shock. The nurse
will assess the patient for which etiologies?(choose all that apply)
A) Anaphylaxis
B) Hemorrhage
C) Sepsis
D) Spinal cord injury
E) Pulmonary embolism - answerA) Anaphylaxis. One etiology of distributive shock is
anaphylaxis
, C) Sepsis. One etiology of distributive shock is sepsis
D) Spinal cord injury. One etiology of distributive shock is spinal cord injury
A patient is experiencing an anaphylactic reaction to a medication. The nurse is
concerned that the patient will develop distributive shock because:
Select one:
A) Sympathetic innervation is interrupted
B) Microorganisms overwhelm the vascular system
C) The release of histamine causes vasodilation with plasma leakage
D) Parasympathetic innervation functions are unopposed. - answerC) The release of
histamine causes vasodilation with plasma leakage. In an anaphylactic reaction leading
to distributive shock, the release of histamine causes vasodilation with plasma leakage.
Vasodilation leads to profound hypotension, hypovolemia from fluid extravasation,
reduced reload, and reduced cardiac output.
The nurse is explaining the mechanism of pulmonary embolism to the family of a patient
diagnosed with the disorder. Place in order the steps the nurse will use to instruct the
family about this disease process.
A) Left ventricle does not get enough blood to pump through the body
B) Blood clot blocks blood to the left ventricle
C) Blood clot causes backup of blood in the right ventricle - answerC, B, A
Rationale 1: The obstruction caused by the pulmonary embolism increases afterload of
the right ventricle, causing right ventricular failure.
Rationale 2: The embolus prevents adequate blood flow from the pulmonary circulation
to the left ventricle.
Rationale 3: Because blood flow from the pulmonary circulation is blocked, left
ventricular preload drops,
Rationale 4: Because left ventricular preload decreased, there is not enough blood in
the heart to pump, causing decreased cardiac output.
Rationale 5: A lack of blood circulating will lead to hypotension.
Rationale 6: When the blood is backed up and is not being pumped into the general
circulation, tissue perfusion is reduced.
A patient being treated for cardiogenic shock is being hemodynamically monitored.
Which findings are consistent with the patient's diagnosis? (select all that apply)
A) Elevated stroke volume
B) Elevated systemic vascular resistance index
C) Elevated central venous pressure
D) Elevated mean arterial pressure
E) Elevated pulmonary arterial wedge pressure - answerB) Elevated systemic vascular
resistance index. This finding is consistent with pulmonary vascular congestion.
What will the nurse identify as symptoms of hypovolemic shock in a patient? (choose all
that apply)
A) Capillary refill time greater than 30 seconds
B) Temperature of 97.6F (36.4C)
C) Decrease in blood pressure of 20 mmHg when the patient sits up
D) Restlessness
E) Sinus bradycardia of 55 beats per minute - answerA) Due to decreased blood flow to
the brain and peripheral areas when blood is shunted to maintain the vital organs,
capillary refill time will be reduced
C) Orthostatic hypotension is a manifestation of hypovolemic shock
D) Due to decreased blood flow to the brain and peripheral areas when blood is shunted
to maintain the vital organs, cerebral hypoxia occurs, leading to change in mental status
Which laboratory finding should cause the nurse to suspect that a patient is developing
hypovolemic shock?
Select one:
A) SvO2 greater than 80%
B) Normal serum lactate of 1 mmol/L
C) Metabolic acidosis validated by arterial blood gases
D) Low serum sodium of 130 mEq/L (130 mmol/L) - answerC) Metabolic acidosis is
present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from
decreased tissue perfusion
The nurse recognizes that which patient would be the most likely to develop
hypovolemic shock? A patient with:
Select one:
A) Sodium retention
B) Decreased cardiac output
C) Severe constipation, causing watery diarrhea
D) Ascites - answerD) Third spacing shifts move the fluids from the intravascular space
into the interstitial space causing a drop in the circulating blood volume. Therefore, third
spacing is a risk factor for the development of hypovolemic shock. Overhydration does
not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic
shock, congestive heart failure, and pulmonary edema.
Which finding indicates that a patient is experiencing increased peripheral resistance
and vasoconstriction?
Select one:
,A) Faster than normal capillary refill times
B) Strong bounding pulse and deep red skin color
C) Pale, cool extremities with decreased pulses
D) Increased venous engorgement with strong pulses - answerC) Increased peripheral
resistance causes the blood supply to decrease and results in decreased blood in the
tissues, which causes pallor and decreased skin temperatures. The pulses would
decrease in intensity with a decreased blood supply.
Which life-threatening complications would the nurse anticipate in the patient being
treated for hypovolemic shock?(choose all that apply)
A) Gastric stress ulcer
B) Pulmonary edema
C) Fluid volume overload
D) Renal insufficiency
E) Cerebral ischemia - answerD) Renal insufficiency is a serious complication because
of the prerenal etiology of hypovolemia,
E) Cerebral ischemia. Early identification and correction of the fluid volume deficit in
hypovolemia shock is necessary to prevent cerebral ischemia.
Which finding indicates that rehydration is complete and hypovolemic shock has been
successfully treated in a patient?
Select one:
A) MAP = 45 mmHg
B) Urinary output of 0.1 mL/kg/hr
C) Hct = 54%
D) CVP = 6 mm HG - answerD) CVP = 6 mm HG. A CVP of 6 mmHg is within normal
range and rehydration has been restored.
A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill.
The nurse suspects the patient is experiencing which type of shock?
Select one:
A) Hypovolemic
B) Obstructive
C) Cardiogenic
D) Anaphylactic - answerC) Cardiogenic. In cardiogenic shock, there is a low cardiac
output, hypotension, and pulmonary edema
A patient is experiencing vasodilation, is diagnosed with distributive shock. The nurse
will assess the patient for which etiologies?(choose all that apply)
A) Anaphylaxis
B) Hemorrhage
C) Sepsis
D) Spinal cord injury
E) Pulmonary embolism - answerA) Anaphylaxis. One etiology of distributive shock is
anaphylaxis
, C) Sepsis. One etiology of distributive shock is sepsis
D) Spinal cord injury. One etiology of distributive shock is spinal cord injury
A patient is experiencing an anaphylactic reaction to a medication. The nurse is
concerned that the patient will develop distributive shock because:
Select one:
A) Sympathetic innervation is interrupted
B) Microorganisms overwhelm the vascular system
C) The release of histamine causes vasodilation with plasma leakage
D) Parasympathetic innervation functions are unopposed. - answerC) The release of
histamine causes vasodilation with plasma leakage. In an anaphylactic reaction leading
to distributive shock, the release of histamine causes vasodilation with plasma leakage.
Vasodilation leads to profound hypotension, hypovolemia from fluid extravasation,
reduced reload, and reduced cardiac output.
The nurse is explaining the mechanism of pulmonary embolism to the family of a patient
diagnosed with the disorder. Place in order the steps the nurse will use to instruct the
family about this disease process.
A) Left ventricle does not get enough blood to pump through the body
B) Blood clot blocks blood to the left ventricle
C) Blood clot causes backup of blood in the right ventricle - answerC, B, A
Rationale 1: The obstruction caused by the pulmonary embolism increases afterload of
the right ventricle, causing right ventricular failure.
Rationale 2: The embolus prevents adequate blood flow from the pulmonary circulation
to the left ventricle.
Rationale 3: Because blood flow from the pulmonary circulation is blocked, left
ventricular preload drops,
Rationale 4: Because left ventricular preload decreased, there is not enough blood in
the heart to pump, causing decreased cardiac output.
Rationale 5: A lack of blood circulating will lead to hypotension.
Rationale 6: When the blood is backed up and is not being pumped into the general
circulation, tissue perfusion is reduced.
A patient being treated for cardiogenic shock is being hemodynamically monitored.
Which findings are consistent with the patient's diagnosis? (select all that apply)
A) Elevated stroke volume
B) Elevated systemic vascular resistance index
C) Elevated central venous pressure
D) Elevated mean arterial pressure
E) Elevated pulmonary arterial wedge pressure - answerB) Elevated systemic vascular
resistance index. This finding is consistent with pulmonary vascular congestion.
