NUR 2243C Exam 2 Questions With Complete Solutions
12. A nurse is caring for several clients at risk for shock. Which
laboratory value requires the nurse to communicate with the
health care provider?
a. Creatinine: 0.9 mg/dL
b. Lactate: 6 mmol/L
c. Sodium: 150 mEq/L
d. White blood cell count: 11,000/mm3
ANS: B
A lactate level of 6 mmol/L is high and is indicative of possible
shock. A creatinine level of 0.9 mg/dL is normal. A sodium
level of 150 mEq/L is high, but that is not related directly to
shock. A white blood cell count of 11,000/mm3 is slightly high
but is not as critical as the lactate level.
13. A client in shock is apprehensive and slightly confused.
What action by the nurse is best?
a. Offer to remain with the client for awhile.
b. Prepare to administer antianxiety medication.
c. Raise all four siderails on the clients bed.
d. Tell the client everything possible is being done.
,ANS: A
The nurses presence will be best to reassure this client.
Antianxiety medication is not warranted as this will lower the
clients blood pressure. Using all four siderails on a hospital bed
is considered a restraint in most facilities, although the nurse
should ensure the clients safety. Telling a confused client that
everything is being done is not the most helpful response.
14. A client is being discharged home after a large myocardial
infarction and subsequent coronary artery bypass grafting
surgery. The clients sternal wound has not yet healed. What
statement by the client most indicates a higher risk of
developing sepsis after discharge?
a. All my friends and neighbors are planning a party for me.
b. I hope I can get my water turned back on when I get home.
c. I am going to have my daughter scoop the cat litter box.
d. My grandkids are so excited to have me coming home!
ANS: B
All these statements indicate a potential for leading to infection
once the client gets back home. A large party might include
individuals who are themselves ill and contagious. Having litter
boxes in the home can expose the client to microbes that can
lead to infection. Small children often have upper respiratory
infections and poor hand hygiene that spread germs. However,
the most worrisome statement is the lack of running water for
handwashing and general hygiene and cleaning purposes.
,15. A client in shock has been started on dopamine. What
assessment finding requires the nurse to communicate with the
provider immediately?
a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1plus/4plus bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr
ANS: C
Chest heaviness or pain indicates myocardial ischemia, a
possible adverse effect of dopamine. While taking dopamine, the
oxygen requirements of the heart are increased due to increased
myocardial workload, and may cause ischemia. Without
knowing the clients previous blood pressure or pedal pulses,
there is not enough information to determine if these are an
improvement or not. A urine output of 32 mL/hr is acceptable.
1. The student nurse studying shock understands that the
common manifestations of this condition are directly related to
which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
, d. Impaired renal perfusion
e. Increased perfusion
ANS: A, C
The common manifestations of shock, no matter the cause, are
directly related to the effects of anaerobic metabolism and
hypotension. Hyperglycemia, impaired renal function, and
increased perfusion are not manifestations of shock.
2. The nurse caring for hospitalized clients includes which
actions on their care plans to reduce the possibility of the clients
developing shock? (Select all that apply.)
a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
ANS: A, C, D, E
Assessing and identifying clients at risk for shock is probably
the most critical action the nurse can take to prevent shock from
occurring. Proper hand hygiene, using aseptic technique, and
removing IV lines and catheters are also important actions to
prevent shock. Monitoring laboratory values does not prevent
shock but can indicate a change.
3. The nurse caring frequently for older adults in the hospital is
aware of risk factors that place them at a higher risk for shock.
For what factors would the nurse assess? (Select all that apply.)
12. A nurse is caring for several clients at risk for shock. Which
laboratory value requires the nurse to communicate with the
health care provider?
a. Creatinine: 0.9 mg/dL
b. Lactate: 6 mmol/L
c. Sodium: 150 mEq/L
d. White blood cell count: 11,000/mm3
ANS: B
A lactate level of 6 mmol/L is high and is indicative of possible
shock. A creatinine level of 0.9 mg/dL is normal. A sodium
level of 150 mEq/L is high, but that is not related directly to
shock. A white blood cell count of 11,000/mm3 is slightly high
but is not as critical as the lactate level.
13. A client in shock is apprehensive and slightly confused.
What action by the nurse is best?
a. Offer to remain with the client for awhile.
b. Prepare to administer antianxiety medication.
c. Raise all four siderails on the clients bed.
d. Tell the client everything possible is being done.
,ANS: A
The nurses presence will be best to reassure this client.
Antianxiety medication is not warranted as this will lower the
clients blood pressure. Using all four siderails on a hospital bed
is considered a restraint in most facilities, although the nurse
should ensure the clients safety. Telling a confused client that
everything is being done is not the most helpful response.
14. A client is being discharged home after a large myocardial
infarction and subsequent coronary artery bypass grafting
surgery. The clients sternal wound has not yet healed. What
statement by the client most indicates a higher risk of
developing sepsis after discharge?
a. All my friends and neighbors are planning a party for me.
b. I hope I can get my water turned back on when I get home.
c. I am going to have my daughter scoop the cat litter box.
d. My grandkids are so excited to have me coming home!
ANS: B
All these statements indicate a potential for leading to infection
once the client gets back home. A large party might include
individuals who are themselves ill and contagious. Having litter
boxes in the home can expose the client to microbes that can
lead to infection. Small children often have upper respiratory
infections and poor hand hygiene that spread germs. However,
the most worrisome statement is the lack of running water for
handwashing and general hygiene and cleaning purposes.
,15. A client in shock has been started on dopamine. What
assessment finding requires the nurse to communicate with the
provider immediately?
a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1plus/4plus bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr
ANS: C
Chest heaviness or pain indicates myocardial ischemia, a
possible adverse effect of dopamine. While taking dopamine, the
oxygen requirements of the heart are increased due to increased
myocardial workload, and may cause ischemia. Without
knowing the clients previous blood pressure or pedal pulses,
there is not enough information to determine if these are an
improvement or not. A urine output of 32 mL/hr is acceptable.
1. The student nurse studying shock understands that the
common manifestations of this condition are directly related to
which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
, d. Impaired renal perfusion
e. Increased perfusion
ANS: A, C
The common manifestations of shock, no matter the cause, are
directly related to the effects of anaerobic metabolism and
hypotension. Hyperglycemia, impaired renal function, and
increased perfusion are not manifestations of shock.
2. The nurse caring for hospitalized clients includes which
actions on their care plans to reduce the possibility of the clients
developing shock? (Select all that apply.)
a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
ANS: A, C, D, E
Assessing and identifying clients at risk for shock is probably
the most critical action the nurse can take to prevent shock from
occurring. Proper hand hygiene, using aseptic technique, and
removing IV lines and catheters are also important actions to
prevent shock. Monitoring laboratory values does not prevent
shock but can indicate a change.
3. The nurse caring frequently for older adults in the hospital is
aware of risk factors that place them at a higher risk for shock.
For what factors would the nurse assess? (Select all that apply.)
