MDC 4 Practice Questions with 100% Verified
Correct Answers
Neurogenic shock is classified as an imbalance of sympathetic and parasympathetic
stimulation. As parasympathetic activity increases, what assessment finding should the
nurse anticipate?
Bradycardia
The nurse prepares a client with cirrhosis and an intestinal obstruction for surgery in 2
hours. The nurse reviews the client's laboratory results and notes the prothrombin time
is 13 seconds, the international normalized ratio is 1.4, and partial thromboplastin time
is 47 sec. What is the nurse's priority action?
Contact the healthcare provider
When assessing a client with a pneumothorax the nurse finds that the trachea has
shifted to the uninvolved side. What additional assessment finding would the nurse
assess for?
Decreased chest expansion on the involved side
A frail older adult client is scheduled for a surgical procedure. How will the surgical
team ensure the client does not experience complications from hypothermia during
surgery? Select all that apply.
Perform close monitoring of the client's temperature
Administer intravenous fluids that are warmed
Have a thermal warming blanket on hand
,A client who was admitted with electrical burns 24 hours ago, is experiencing
ventricular tachycardia. How should the nurse interpret this finding?
The heart rhythm is directly related to the electrical burn
The nurse cares for a client who had surgery 16 hours ago. What assessment finding
prompts the nurse to call the surgeon?
Constant pain and abdominal distention
A client in shock is receiving dopamine in addition to IV fluids. Which principle will
guide the nurse's care planning during the administration of this vasoactive drug?
Select all that apply.
The drug should be administered through a central venous line
The drug dose should be tapered down once vital signs improve
The infusion rate should be titrated for a mean arterial pressure (MAP) of 65
A nurse in the ICU receives report from the nurse in the ED about a new client being
admitted who sustained a neck injury while diving into a lake. The ED nurse reports
that blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and
dry. What does the ICU nurse recognize that that client is probably experiencing?
Neurogenic shock
The nurse in the ICU is admitting a 57-year-old with a diagnosis of possible septic
shock. The nurse's assessment reveals that the client has a normal blood pressure,
increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's
analysis of these data should lead to what preliminary conclusion?
, The client is in the compensatory stage of shock
A client with cardiogenic shock is receiving dobutamine to improve myocardial
contractility. Which complication should the nurse carefully monitor for?
Tachyarrhythmias
A client with distributive shock is receiving norepinephrine to maintain blood pressure.
What complication of this drug could require physician notification?
Peripheral ischemia
A client with suspected septic shock has a respiratory rate of 28 breaths per minute,
altered mentation, and blood pressure of 78/43 mmHg (MAP 55). Which action should
the nurse take first?
Begin rapid administration of 30 mL/kg crystalloid for hypotension
A client in the compensatory stage of shock is experiencing a narrowing pulse pressure,
cool and pale skin, and decreased urine output. The nurse recognizes these findings as
consistent with which physiological response?
Sympathetic nervous system response resulting in shunting of blood to vital organs
A client with a known peanut allergy suddenly develops wheezing, hypotension, and
urticaria after eating a dessert. Which medication should the nurse administer first?
Intramuscular epinephrine
A client is admitted to the emergency department with signs of hypovolemic shock
following a severe gastrointestinal bleed. The nurse notes that the client is tachycardic,
hypotensive, and has cool, clammy skin. Which of the following interventions should the
nurse prioritize to address the underlying cause of the client's condition?
Correct Answers
Neurogenic shock is classified as an imbalance of sympathetic and parasympathetic
stimulation. As parasympathetic activity increases, what assessment finding should the
nurse anticipate?
Bradycardia
The nurse prepares a client with cirrhosis and an intestinal obstruction for surgery in 2
hours. The nurse reviews the client's laboratory results and notes the prothrombin time
is 13 seconds, the international normalized ratio is 1.4, and partial thromboplastin time
is 47 sec. What is the nurse's priority action?
Contact the healthcare provider
When assessing a client with a pneumothorax the nurse finds that the trachea has
shifted to the uninvolved side. What additional assessment finding would the nurse
assess for?
Decreased chest expansion on the involved side
A frail older adult client is scheduled for a surgical procedure. How will the surgical
team ensure the client does not experience complications from hypothermia during
surgery? Select all that apply.
Perform close monitoring of the client's temperature
Administer intravenous fluids that are warmed
Have a thermal warming blanket on hand
,A client who was admitted with electrical burns 24 hours ago, is experiencing
ventricular tachycardia. How should the nurse interpret this finding?
The heart rhythm is directly related to the electrical burn
The nurse cares for a client who had surgery 16 hours ago. What assessment finding
prompts the nurse to call the surgeon?
Constant pain and abdominal distention
A client in shock is receiving dopamine in addition to IV fluids. Which principle will
guide the nurse's care planning during the administration of this vasoactive drug?
Select all that apply.
The drug should be administered through a central venous line
The drug dose should be tapered down once vital signs improve
The infusion rate should be titrated for a mean arterial pressure (MAP) of 65
A nurse in the ICU receives report from the nurse in the ED about a new client being
admitted who sustained a neck injury while diving into a lake. The ED nurse reports
that blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and
dry. What does the ICU nurse recognize that that client is probably experiencing?
Neurogenic shock
The nurse in the ICU is admitting a 57-year-old with a diagnosis of possible septic
shock. The nurse's assessment reveals that the client has a normal blood pressure,
increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's
analysis of these data should lead to what preliminary conclusion?
, The client is in the compensatory stage of shock
A client with cardiogenic shock is receiving dobutamine to improve myocardial
contractility. Which complication should the nurse carefully monitor for?
Tachyarrhythmias
A client with distributive shock is receiving norepinephrine to maintain blood pressure.
What complication of this drug could require physician notification?
Peripheral ischemia
A client with suspected septic shock has a respiratory rate of 28 breaths per minute,
altered mentation, and blood pressure of 78/43 mmHg (MAP 55). Which action should
the nurse take first?
Begin rapid administration of 30 mL/kg crystalloid for hypotension
A client in the compensatory stage of shock is experiencing a narrowing pulse pressure,
cool and pale skin, and decreased urine output. The nurse recognizes these findings as
consistent with which physiological response?
Sympathetic nervous system response resulting in shunting of blood to vital organs
A client with a known peanut allergy suddenly develops wheezing, hypotension, and
urticaria after eating a dessert. Which medication should the nurse administer first?
Intramuscular epinephrine
A client is admitted to the emergency department with signs of hypovolemic shock
following a severe gastrointestinal bleed. The nurse notes that the client is tachycardic,
hypotensive, and has cool, clammy skin. Which of the following interventions should the
nurse prioritize to address the underlying cause of the client's condition?
