Shock NCLEX Questions, NCLEX Questions For Shock - Critical Care,
Sepsis NCLEX, Ch 67: Shock, SIRS, MODS
A patient is admitted to the emergency 2. Restlessness
department after sustaining abdominal injuries 3. Decrease in blood pressure of 20 mm Hg
and a broken femur from a motor vehicle when the patient sits up
accident. The patient is pale, diaphoretic, and is4. Capillary refill time greater than 3 seconds
not talking coherently. Vital signs upon admission5. Sinus bradycardia of 55 beats per minute -
are temperature 98 F (36 C), heart rate 130 ANSWER -Correct Answer: 2,3,4
beats/minute, respiratory rate 34 breaths/minute, Rationale 1: Fever will increase oxygen demands
blood pressure 50/40 mmHg. The healthcare but is unrelated to hypovolemic shock unless
provider suspects which type of shock? prolonged fever has caused severe dehydration,
reducing the circulating blood volume.
a.) Hypovolemic Hypovolemic shock reduces temperatures by
b.) Cardiogenic peripheral shunting of blood away from the
c.) Neurogenic extremities and reducing the core metabolic rate.
d.) Distributive - ANSWER -a.) Rationale 2: Due to decreased blood flow to the
Hypovolemic brain and peripheral areas when blood is shunted
to maintain the vital organs, cerebral hypoxia
occurs, leading to a change in mental status.
1. A patient with septic shock has a urine output Rationale 3: Orthostatic hypotension is a
of 20 mL/hr for the past 3 hours. The pulse manifestation of hypovolemic shock.
rate is 120 and the central venous pressure and Rationale 4: Due to decreased blood flow to the
pulmonary artery wedge pressure are low. brain and peripheral areas when blood is shunted
Which of these orders by the health care provider to maintain the vital organs, capillary refill time
will the nurse question? will be reduced.
a. Give furosemide (Lasix) 40 mg IV. Rationale 5: Bradycardia is not present. The
b. Increase normal saline infusion to 150 mL/hr. compensatory response is to increase the heart
c. Administer hydrocortisone (SoluCortef) 100 rate to circulate the blood faster to make up for
mg IV. the fluids that are not present in hypovolemic
d. Prepare to give drotrecogin alpha (Xigris) 24 shock.
mcg/kg/hr. - ANSWER -ANS: A
Furosemide will lower the filling pressures and
renal perfusion further for the patient Why are the manifestations of most types of
with septic shock. The other orders are shock the same regardless of what specific
appropriate. events or condition caused the shock to occur?
DIF: Cognitive Level: Application REF: 1724- A. The blood, blood vessels, and heart are
1726 | 1731 | 1733 directly connected to each other so that when
TOP: Nursing Process: Implementation MSC: one is affected, all three are affected.
NCLEX: Physiological Integrity B. Because blood loss occurs with all types of
shock, the most common first manifestation is
hypotension.
What will the nurse identify as symptoms of C. Every type of shock interferes with
hypovolemic shock in a patient? oxygenation and metabolism of all cells in the
Note: Credit will be given only if all correct same sequence.
choices and no incorrect choices are selected. D. The sympathetic nervous system is triggered
Standard Text: Select all that apply. by any type of shock and initiates the stress
1. Temperature of 97.6°F (36.4°C) response. - ANSWER -ANS: D
,Shock NCLEX Questions, NCLEX Questions For Shock - Critical Care,
Sepsis NCLEX, Ch 67: Shock, SIRS, MODS
Rationale: Most manifestations of shock are b.) Administer dopamine
similar regardless of what starts the process or c.) No interventions are needed at this time
which tissues are affected first. These common d.) Increase the IV infusion rate -
manifestations result from physiologic ANSWER -d.) Increase the IV infusion rate
adjustments (compensatory mechanisms) in an
attempt to ensure continued oxygenation of vital
organs. These adjustment actions are performed Which vital sign change in a client with
by the sympathetic nervous system triggering the hypovolemic shock indicates to the nurse that the
stress response and activating the endocrine and therapy is effective?
cardiovascular systems. A. Urine output increase from 5 mL/hr to 25
mL/hr
B. Pulse pressure decrease from 35 mm Hg to 28
2. A patient with shock of unknown etiology mm Hg
whose hemodynamic monitoring indicates BP C. Respiratory rate increase from 22 breaths/min
92/54, pulse 64, and an elevated pulmonary to 26 breaths/min
artery wedge pressure has the following D. Core body temperature increase from 98.2 F
collaborative interventions prescribed. Which (36.8 C) to 98.8 F (37.1 C) - ANSWER -
intervention will the nurse question? ANS: A
a. Infuse normal saline at 250 mL/hr. Rationale: During shock, the kidneys and
b. Keep head of bed elevated to 30 degrees. baroreceptors sense an ongoing decrease in
c. Give nitroprusside (Nipride) unless systolic BP MAP and trigger the release of renin, antidiuretic
<90 mm Hg. hormone (ADH), aldosterone, epinephrine, and
d. Administer dobutamine (Dobutrex) to keep norepinephrine to start kidney compensation,
systolic BP >90 mm Hg. - ANSWER -ANS: which is very sensitive to changes in fluid
A volume. Renin, secreted by the kidney, causes
The patient's elevated pulmonary artery wedge decreased urine output. ADH increases water
pressure indicates volume excess. A reabsorption in the kidney, further reducing urine
normal saline infusion at 250 mL/hr will output. These actions compensate for shock by
exacerbate this. The other actions are attempting to prevent further fluid loss. This
appropriate for the patient. response is so sensitive that urine output is a
DIF: Cognitive Level: Application REF: 1719 | very good indicator of fluid resuscitation
1721-1722 | 1735 adequacy. If the therapy is not effective, urine
TOP: Nursing Process: Planning MSC: NCLEX: output does not increase.
Physiological Integrity
Which laboratory finding should cause the nurse
The healthcare provider is caring for a patient to suspect that a patient is developing
with a diagnosis of hemorrhagic pancreatitis. The hypovolemic shock?
patient's central venous pressure (CVP) reading 1. Serum sodium of 130 mEq/L (130 mmol/L)
is 2, blood pressure is 90/50 mmHg, lung sounds 2. Metabolic acidosis validated by arterial blood
are clear, and jugular veins are flat. Which of gases
these actions is most appropriate for the nurse to 3. Serum lactate of 3 mmol/L
take? 4. SvO2 greater than 80% - ANSWER -
Correct Answer: 2
a.) Slow the IV infusion rate Rationale 1: The sodium level in hypovolemic
,Shock NCLEX Questions, NCLEX Questions For Shock - Critical Care,
Sepsis NCLEX, Ch 67: Shock, SIRS, MODS
shock is elevated above the normal values of ANSWER -Correct Answer: 3
135 to 145 mEq/L, not reduced. Rationale 1: Although ECG changes reflect the
Rationale 2: Metabolic acidosis is present due to effectiveness of the heart's pumping when
an accumulation of carbonic acid, leaving a circulating the blood, it is not a risk factor for
bicarbonate deficit from decreased tissue hypovolemic shock, which reflects a decreased
perfusion. circulating volume from either blood or fluid
Rationale 3: Serum lactate is greater than 4 losses within the intravascular system.
mmol/L as a result of tissue ischemia, hypoxia, Rationale 2: Severe constipation does not affect
and breakdown from decreased blood flow with the circulating blood volume.
hypovolemic shock. Rationale 3: Third spacing shifts move the fluids
Rationale 4: SvO2 (mixed venous oxygen from the intravascular space into the interstitial
saturation) would be less than 60% due to space, causing a drop in the circulating blood
decreased circulating blood volume or decrease volume. Therefore, third spacing is a risk factor
in cells to carry the oxygen. Therefore, O2 is for the development of hypovolemic shock.
carried less efficiently and decreased, not Rationale 4: Overhydration does not lead to
increased. hypovolemic shock. It leads to fluid overload,
which might cause cardiogenic shock, congestive
heart failure, and pulmonary edema.
A patient who has pericarditis related to radiation
therapy, becomes dyspneic, and has a rapid,
weak pulse. Heart sounds are muffled, and a 12 Which newly admitted client does the nurse
mmHg drop in blood pressure is noted on consider to be at highest risk for development of
inspiration. The healthcare provider's sepsis?
interventions are aimed at preventing which type A. 75-year-old man with hypertension and early
of shock? Alzheimer's disease
B. 68-year-old woman 2 days postoperative from
a.) Distributive bowel surgery
b.) Neurogenic C. 80-year-old community-dwelling man with no
c.) Obstructive other health problems undergoing cataract
d.) Cardiogenic - ANSWER -c.) Obstructive surgery
D. 54-year-old woman with moderate asthma and
Rationale: severe degenerative joint disease of the right
Obstructive shock can be caused by anything knee - ANSWER -ANS: B
that impedes the heart's ability to contract and Rationale: The 68-year-old woman has several
pump blood around the body, as with cardiac risk factors. First she is an older adult, and
tamponade. immune function decreases with age. The
greatest risk factor is that she has just had bowel
surgery. Not only does major surgery further
The nurse recognizes that which patient would reduce the immune response, the bowel cannot
be most likely to develop hypovolemic shock? A be "sterilized" for surgery. Therefore the usual
patient with: bacteria of the bowel have the chance to escape
1. Decreased cardiac output the site and enter the bloodstream when the
2. Severe constipation, causing watery diarrhea bowel is disrupted.
3. Ascites
4. Syndrome of inappropriate ADH (SIADH) -
, Shock NCLEX Questions, NCLEX Questions For Shock - Critical Care,
Sepsis NCLEX, Ch 67: Shock, SIRS, MODS
3. A patient with massive trauma and possible bleeding?
spinal cord injury is admitted to the His left kidney could have been jarred with this
emergency department (ED). Which finding by injury even though the blow occurred to the
the nurse will help confirm a diagnosis of abdomen rather than the back (the kidney is
neurogenic shock? located on the posterior abdominal wall). Check
a. Cool, clammy skin any urine for gross or occult blood. If he has been
b. Inspiratory crackles lying down, blood released as a result of internal
c. Apical heart rate 48 beats/min bleeding could pool in the posterior area as a
d. Temperature 101.2° F (38.4° C) - result of gravity. Therefore check his lower back
ANSWER -ANS: C area.
Neurogenic shock is characterized by 2. What manifestations of shock are present?
hypotension and bradycardia. The other findings The patient has a rapid pulse, narrowed pulse
would be more consistent with other types of pressure, oxygen saturation below 98% (he is
shock. young and, with no other health problems, should
DIF: Cognitive Level: Comprehension REF: have an oxygen saturation of 98% or higher), and
1721-1722 | 1723 he is thirsty.
TOP: Nursing Process: Assessment MSC: 3. How would you classify this stage of shock?
NCLEX: Physiological Integrity Provide a rationale for your evaluation.
He is most likely in the nonprogressive stage of
shock. He is thirsty, indicating that hormonal
A 30-year-old man comes to the emergency compensatory mechanisms have started. In
department because of increasing pain in the left addition, his oxygen saturation is lower than
upper abdominal quadrant. Several hours ago, normal for his age and health. Because his usual
he was hit hard in that area during a tackle by blood pressure is unknown, the shock stage
the head of a football player who was wearing a cannot be established on that basis.
helmet. He has no other health problems, and 4. What additional information should you obtain?
the only drug he takes on a regular basis is 325 Ask the patient if he knows his usual blood
mg of aspirin daily. These are his vital signs: pressure. If he has been to this hospital system
pulse, 102; respirations, 22; blood pressure, before, this information might be available in his
110/86; oxygen saturation, 96%. He has not electronic medical record. Ask when he last
eaten since he was hit but did drink a bottle of urinated and how much. If he is able to urinate,
water on the way to the hospital because he was measure the amount and check for blood. If he
thirsty. When you examine his abdomen, bruising cannot urinate, scan his bladder to determine
is present in the left upper quadrant and extends whether he has produced any urine. Assess nail
down his left side. beds and oral mucous membranes for pallor or
1. Where else should you look for evidence of cyanosis. Also check capillary refill. Determine
bleeding? whether he can take a deep breath. He was hit in
2. What manifestations of shock are present? the upper quadrant, and it is possible that a rib
3. How would you classify this stage of shock? could be fractured. He should have blood drawn
Provide a rationale for your evaluation. for a hematocrit (and possibly hemoglobin) level,
4. What additional information should you although this mus
obtain?
5. What vital - ANSWER -Suggested
Responses: 4. A patient with cardiogenic shock is cool and
1. Where else should you look for evidence of clammy and hemodynamic monitoring
indicates a high systemic vascular resistance
Sepsis NCLEX, Ch 67: Shock, SIRS, MODS
A patient is admitted to the emergency 2. Restlessness
department after sustaining abdominal injuries 3. Decrease in blood pressure of 20 mm Hg
and a broken femur from a motor vehicle when the patient sits up
accident. The patient is pale, diaphoretic, and is4. Capillary refill time greater than 3 seconds
not talking coherently. Vital signs upon admission5. Sinus bradycardia of 55 beats per minute -
are temperature 98 F (36 C), heart rate 130 ANSWER -Correct Answer: 2,3,4
beats/minute, respiratory rate 34 breaths/minute, Rationale 1: Fever will increase oxygen demands
blood pressure 50/40 mmHg. The healthcare but is unrelated to hypovolemic shock unless
provider suspects which type of shock? prolonged fever has caused severe dehydration,
reducing the circulating blood volume.
a.) Hypovolemic Hypovolemic shock reduces temperatures by
b.) Cardiogenic peripheral shunting of blood away from the
c.) Neurogenic extremities and reducing the core metabolic rate.
d.) Distributive - ANSWER -a.) Rationale 2: Due to decreased blood flow to the
Hypovolemic brain and peripheral areas when blood is shunted
to maintain the vital organs, cerebral hypoxia
occurs, leading to a change in mental status.
1. A patient with septic shock has a urine output Rationale 3: Orthostatic hypotension is a
of 20 mL/hr for the past 3 hours. The pulse manifestation of hypovolemic shock.
rate is 120 and the central venous pressure and Rationale 4: Due to decreased blood flow to the
pulmonary artery wedge pressure are low. brain and peripheral areas when blood is shunted
Which of these orders by the health care provider to maintain the vital organs, capillary refill time
will the nurse question? will be reduced.
a. Give furosemide (Lasix) 40 mg IV. Rationale 5: Bradycardia is not present. The
b. Increase normal saline infusion to 150 mL/hr. compensatory response is to increase the heart
c. Administer hydrocortisone (SoluCortef) 100 rate to circulate the blood faster to make up for
mg IV. the fluids that are not present in hypovolemic
d. Prepare to give drotrecogin alpha (Xigris) 24 shock.
mcg/kg/hr. - ANSWER -ANS: A
Furosemide will lower the filling pressures and
renal perfusion further for the patient Why are the manifestations of most types of
with septic shock. The other orders are shock the same regardless of what specific
appropriate. events or condition caused the shock to occur?
DIF: Cognitive Level: Application REF: 1724- A. The blood, blood vessels, and heart are
1726 | 1731 | 1733 directly connected to each other so that when
TOP: Nursing Process: Implementation MSC: one is affected, all three are affected.
NCLEX: Physiological Integrity B. Because blood loss occurs with all types of
shock, the most common first manifestation is
hypotension.
What will the nurse identify as symptoms of C. Every type of shock interferes with
hypovolemic shock in a patient? oxygenation and metabolism of all cells in the
Note: Credit will be given only if all correct same sequence.
choices and no incorrect choices are selected. D. The sympathetic nervous system is triggered
Standard Text: Select all that apply. by any type of shock and initiates the stress
1. Temperature of 97.6°F (36.4°C) response. - ANSWER -ANS: D
,Shock NCLEX Questions, NCLEX Questions For Shock - Critical Care,
Sepsis NCLEX, Ch 67: Shock, SIRS, MODS
Rationale: Most manifestations of shock are b.) Administer dopamine
similar regardless of what starts the process or c.) No interventions are needed at this time
which tissues are affected first. These common d.) Increase the IV infusion rate -
manifestations result from physiologic ANSWER -d.) Increase the IV infusion rate
adjustments (compensatory mechanisms) in an
attempt to ensure continued oxygenation of vital
organs. These adjustment actions are performed Which vital sign change in a client with
by the sympathetic nervous system triggering the hypovolemic shock indicates to the nurse that the
stress response and activating the endocrine and therapy is effective?
cardiovascular systems. A. Urine output increase from 5 mL/hr to 25
mL/hr
B. Pulse pressure decrease from 35 mm Hg to 28
2. A patient with shock of unknown etiology mm Hg
whose hemodynamic monitoring indicates BP C. Respiratory rate increase from 22 breaths/min
92/54, pulse 64, and an elevated pulmonary to 26 breaths/min
artery wedge pressure has the following D. Core body temperature increase from 98.2 F
collaborative interventions prescribed. Which (36.8 C) to 98.8 F (37.1 C) - ANSWER -
intervention will the nurse question? ANS: A
a. Infuse normal saline at 250 mL/hr. Rationale: During shock, the kidneys and
b. Keep head of bed elevated to 30 degrees. baroreceptors sense an ongoing decrease in
c. Give nitroprusside (Nipride) unless systolic BP MAP and trigger the release of renin, antidiuretic
<90 mm Hg. hormone (ADH), aldosterone, epinephrine, and
d. Administer dobutamine (Dobutrex) to keep norepinephrine to start kidney compensation,
systolic BP >90 mm Hg. - ANSWER -ANS: which is very sensitive to changes in fluid
A volume. Renin, secreted by the kidney, causes
The patient's elevated pulmonary artery wedge decreased urine output. ADH increases water
pressure indicates volume excess. A reabsorption in the kidney, further reducing urine
normal saline infusion at 250 mL/hr will output. These actions compensate for shock by
exacerbate this. The other actions are attempting to prevent further fluid loss. This
appropriate for the patient. response is so sensitive that urine output is a
DIF: Cognitive Level: Application REF: 1719 | very good indicator of fluid resuscitation
1721-1722 | 1735 adequacy. If the therapy is not effective, urine
TOP: Nursing Process: Planning MSC: NCLEX: output does not increase.
Physiological Integrity
Which laboratory finding should cause the nurse
The healthcare provider is caring for a patient to suspect that a patient is developing
with a diagnosis of hemorrhagic pancreatitis. The hypovolemic shock?
patient's central venous pressure (CVP) reading 1. Serum sodium of 130 mEq/L (130 mmol/L)
is 2, blood pressure is 90/50 mmHg, lung sounds 2. Metabolic acidosis validated by arterial blood
are clear, and jugular veins are flat. Which of gases
these actions is most appropriate for the nurse to 3. Serum lactate of 3 mmol/L
take? 4. SvO2 greater than 80% - ANSWER -
Correct Answer: 2
a.) Slow the IV infusion rate Rationale 1: The sodium level in hypovolemic
,Shock NCLEX Questions, NCLEX Questions For Shock - Critical Care,
Sepsis NCLEX, Ch 67: Shock, SIRS, MODS
shock is elevated above the normal values of ANSWER -Correct Answer: 3
135 to 145 mEq/L, not reduced. Rationale 1: Although ECG changes reflect the
Rationale 2: Metabolic acidosis is present due to effectiveness of the heart's pumping when
an accumulation of carbonic acid, leaving a circulating the blood, it is not a risk factor for
bicarbonate deficit from decreased tissue hypovolemic shock, which reflects a decreased
perfusion. circulating volume from either blood or fluid
Rationale 3: Serum lactate is greater than 4 losses within the intravascular system.
mmol/L as a result of tissue ischemia, hypoxia, Rationale 2: Severe constipation does not affect
and breakdown from decreased blood flow with the circulating blood volume.
hypovolemic shock. Rationale 3: Third spacing shifts move the fluids
Rationale 4: SvO2 (mixed venous oxygen from the intravascular space into the interstitial
saturation) would be less than 60% due to space, causing a drop in the circulating blood
decreased circulating blood volume or decrease volume. Therefore, third spacing is a risk factor
in cells to carry the oxygen. Therefore, O2 is for the development of hypovolemic shock.
carried less efficiently and decreased, not Rationale 4: Overhydration does not lead to
increased. hypovolemic shock. It leads to fluid overload,
which might cause cardiogenic shock, congestive
heart failure, and pulmonary edema.
A patient who has pericarditis related to radiation
therapy, becomes dyspneic, and has a rapid,
weak pulse. Heart sounds are muffled, and a 12 Which newly admitted client does the nurse
mmHg drop in blood pressure is noted on consider to be at highest risk for development of
inspiration. The healthcare provider's sepsis?
interventions are aimed at preventing which type A. 75-year-old man with hypertension and early
of shock? Alzheimer's disease
B. 68-year-old woman 2 days postoperative from
a.) Distributive bowel surgery
b.) Neurogenic C. 80-year-old community-dwelling man with no
c.) Obstructive other health problems undergoing cataract
d.) Cardiogenic - ANSWER -c.) Obstructive surgery
D. 54-year-old woman with moderate asthma and
Rationale: severe degenerative joint disease of the right
Obstructive shock can be caused by anything knee - ANSWER -ANS: B
that impedes the heart's ability to contract and Rationale: The 68-year-old woman has several
pump blood around the body, as with cardiac risk factors. First she is an older adult, and
tamponade. immune function decreases with age. The
greatest risk factor is that she has just had bowel
surgery. Not only does major surgery further
The nurse recognizes that which patient would reduce the immune response, the bowel cannot
be most likely to develop hypovolemic shock? A be "sterilized" for surgery. Therefore the usual
patient with: bacteria of the bowel have the chance to escape
1. Decreased cardiac output the site and enter the bloodstream when the
2. Severe constipation, causing watery diarrhea bowel is disrupted.
3. Ascites
4. Syndrome of inappropriate ADH (SIADH) -
, Shock NCLEX Questions, NCLEX Questions For Shock - Critical Care,
Sepsis NCLEX, Ch 67: Shock, SIRS, MODS
3. A patient with massive trauma and possible bleeding?
spinal cord injury is admitted to the His left kidney could have been jarred with this
emergency department (ED). Which finding by injury even though the blow occurred to the
the nurse will help confirm a diagnosis of abdomen rather than the back (the kidney is
neurogenic shock? located on the posterior abdominal wall). Check
a. Cool, clammy skin any urine for gross or occult blood. If he has been
b. Inspiratory crackles lying down, blood released as a result of internal
c. Apical heart rate 48 beats/min bleeding could pool in the posterior area as a
d. Temperature 101.2° F (38.4° C) - result of gravity. Therefore check his lower back
ANSWER -ANS: C area.
Neurogenic shock is characterized by 2. What manifestations of shock are present?
hypotension and bradycardia. The other findings The patient has a rapid pulse, narrowed pulse
would be more consistent with other types of pressure, oxygen saturation below 98% (he is
shock. young and, with no other health problems, should
DIF: Cognitive Level: Comprehension REF: have an oxygen saturation of 98% or higher), and
1721-1722 | 1723 he is thirsty.
TOP: Nursing Process: Assessment MSC: 3. How would you classify this stage of shock?
NCLEX: Physiological Integrity Provide a rationale for your evaluation.
He is most likely in the nonprogressive stage of
shock. He is thirsty, indicating that hormonal
A 30-year-old man comes to the emergency compensatory mechanisms have started. In
department because of increasing pain in the left addition, his oxygen saturation is lower than
upper abdominal quadrant. Several hours ago, normal for his age and health. Because his usual
he was hit hard in that area during a tackle by blood pressure is unknown, the shock stage
the head of a football player who was wearing a cannot be established on that basis.
helmet. He has no other health problems, and 4. What additional information should you obtain?
the only drug he takes on a regular basis is 325 Ask the patient if he knows his usual blood
mg of aspirin daily. These are his vital signs: pressure. If he has been to this hospital system
pulse, 102; respirations, 22; blood pressure, before, this information might be available in his
110/86; oxygen saturation, 96%. He has not electronic medical record. Ask when he last
eaten since he was hit but did drink a bottle of urinated and how much. If he is able to urinate,
water on the way to the hospital because he was measure the amount and check for blood. If he
thirsty. When you examine his abdomen, bruising cannot urinate, scan his bladder to determine
is present in the left upper quadrant and extends whether he has produced any urine. Assess nail
down his left side. beds and oral mucous membranes for pallor or
1. Where else should you look for evidence of cyanosis. Also check capillary refill. Determine
bleeding? whether he can take a deep breath. He was hit in
2. What manifestations of shock are present? the upper quadrant, and it is possible that a rib
3. How would you classify this stage of shock? could be fractured. He should have blood drawn
Provide a rationale for your evaluation. for a hematocrit (and possibly hemoglobin) level,
4. What additional information should you although this mus
obtain?
5. What vital - ANSWER -Suggested
Responses: 4. A patient with cardiogenic shock is cool and
1. Where else should you look for evidence of clammy and hemodynamic monitoring
indicates a high systemic vascular resistance
