Nursing Care of Patients in Shock
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient who
... [Show More] has gastrointestinal bleeding is awake, alert, and oriented. The patient’s vital signs are: blood
pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C).
Which of this patient’s data collection findings should the nurse consider as a possible sign of early shock?
a. Blood pressure 130/90 mm Hg
b. Heart rate 118 beats/min
c. Respirations 18/min
d. Temperature 98.6°F (37°C)
____ 2. A patient with gastrointestinal bleeding has a hemoglobin of 8.5 g/dL. As the nurse assists the patient, who is
anxious and irritable, the patient’s nasogastric drainage becomes bright red, pulse 130 beats/minute, blood
pressure 105/55 mm Hg, respirations 28/minute. The nurse recognizes which of the following is likely responsible for the changes in the patient’s vital signs?
a. Early shock
b. Patient anxiety
c. Progressive shock
d. Parasympathetic response
____ 3. Data collection findings for a patient involved in a motor vehicle accident include pale mucous membranes,
diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which
of these does the nurse recognize as the likely cause of this acidosis?
a. Inadequate ventilation
b. Hyperventilation
c. Aerobic metabolism
d. Anaerobic metabolism
____ 4. A patient experiencing progressive shock is diaphoretic, is confused, has a blood pressure of 82/40 mm Hg,
and has a urinary catheter output of 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?
a. Irrigate urinary catheter.
b. Encourage oral fluids.
c. Check urinary catheter for kinking.
d. Increase IV fluid infusion rate.
____ 5. The nurse is caring for a patient who has hypovolemic shock and oliguria due to hemorrhage. The nurse recognizes that which of the following is the most likely cause of the patient’s oliguria?
a. Inadequate oral fluid intake
b. Secretion of aldosterone
c. End-stage renal failure
d. Obstructed urinary catheter
____ 6. On arrival in the emergency department, a patient who was in a motor vehicle accident is reported to be apprehensive, confused, hypotensive, tachycardic, and oliguric, with cool and clammy skin. What should the
nurse do first?
a. Perform a rapid head-to-toe assessment.
b. Obtain patient’s medical history from family.
c. Cover patient with warm blankets.
d. Reorient the patient to person, place, and time.
____ 7. 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 intravenous fluids at 150 mL/hour, has a
blood transfusion infusing, and is being provided oxygen via a mask. Which of the following does the nurse
recognize as the most likely cause of the patient’s respiratory rate?
a. Electrolyte imbalances
b. Inadequate tissue perfusion
c. Reaction to the blood transfusion
d. Rapid rate of fluid replacement
____ 8. Despite aggressive treatment, the condition of a patient who is in shock continues to worsen. Surgical intervention stops the bleeding, and the shock stabilizes. Which of the following findings would require immediate
action by the nurse?
a. Pupils are equally reactive to light.
b. Bowel sounds are hypoactive.
c. Urinary output is 15 mL/hour.
d. The blood pH is 7.36.
____ 9. 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. The nurse recognizes that these abnormalities indicate
damage to which of these organs?
a. Heart
b. Intestines
c. Kidneys
d. Liver
____ 10. After an episode of shock, a patient’s laboratory results reveal decreased clotting factors. Based on these laboratory results, the nurse monitors for signs of which complication of shock?
a. Brain attack
b. Disseminated intravascular coagulation
c. Multisystem organ failure
d. Adult respiratory distress syndrome
____ 11. A patient’s family asks the nurse what shock is. Which of the following statements by the nurse would be
most appropriate?
a. “It is a profound circulatory collapse.”
b. “There is inadequate oxygen delivered to the tissues.”
c. “It is the result of overwhelming emotion.”
d. “It is caused by massive blood loss.”
____ 12. A patient presents with findings of anaphylactic shock. Which of the following nursing actions is the first priority?
a. Provide patient teaching.
b. Ensure a patent airway.
c. Obtain a detailed patient history.
d. Provide pain relief.
____ 13. The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a
patient who is experiencing shock. Which of the following benefits do these measures provide?
a. Decreased fluid volume
b. Increased fluid volume
c. Decreased oxygen demand [Show Less]