39

Chapter 39: Care of Patients with Shock
Test Bank
MULTIPLE CHOICE
1. The intensive care nurse is educating the spouse of a client who is being treated for shock. The
spouse states, The doctor said she has shock. What is that? What is the nurses best
response?
a. Shock occurs when oxygen to the bodys tissues and organs is impaired.
b. Shock is a serious condition, but it is not a life-threatening emergency.
c. Shock progresses slowly and can be stopped by the bodys normal compensation.
d. Shock is a condition that affects only specific body organs like the kidneys.
ANS: A
Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of
shock and lead to a life-threatening emergency. Shock represents the whole-body response,
affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain
homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal
of the cause of shock, resulting in death.
DIF: Cognitive Level: Knowledge/Remembering
REF: p. 809
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is caring for multiple clients in the emergency department. The client with which
condition is at highest risk for distributive shock?

Severe head injury from a motor vehicle accident
Diabetes insipidus from polycystic kidney disease
Ischemic cardiomyopathy from severe coronary artery disease
Vomiting of blood from a gastrointestinal ulcer
a.
b.
c.
d.
ANS: A
Distributive shock is the type of shock that occurs when blood volume is not lost from the
body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen.
Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord
injury, or head trauma. The other clients are at risk for hypovolemic and cardiogenic shock.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 812
MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates
that the client is at risk for acidosis?

Decreased serum creatinine
Increased serum lactic acid
Increased urine specific gravity
Decreased partial pressure of arterial carbon dioxide
a.
b.
c.
d.
ANS: B
The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation;
thus some cells are metabolizing anaerobically. Such metabolism increases the production of
lactic acid, resulting in an increase in hydrogen ion production and acidosis. Other laboratory
values associated with acidosis include increased creatinine (impaired renal function) and
increased partial pressure of arterial carbon dioxide. Urine specific gravity is not associated
with acidosis.
REF: p. 812
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory
Values)
MSC: Integrated Process: Nursing Process (Analysis)
4. A client brought to the emergency department after a motor vehicle accident is suspected of
having internal bleeding. Which question does the nurse ask to determine whether the client is
in the early stages of hypovolemic shock?
a. Are you more thirsty than normal?
b. When was the last time you urinated?
c. What is your normal heart rate?
d. Is your skin usually cool and pale?
ANS: C
The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs
of shock are first evident as changes in cardiovascular function. As shock progresses, changes
in skin, respiration, and kidney function progress. The other questions would not identify early
stages of shock.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
5. A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous
fluid replacement. Which fluid does the nurse prepare to administer?

Normal saline
Ringers lactate
5% dextrose in water
5% dextrose in 0.45% normal saline
a.
b.
c.
d.
ANS: B
Ringers lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as
a buffer in the presence of acidosis. The other solutions do not contain any substance that
would buffer or correct the clients acidosis.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Parenteral/Intravenous Therapies)
6. The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine
hydrochloride (Intropin) drip. Which manifestation is a desired response to this medication?

a. Decrease in blood pressure
b. Increase in heart rate
c. Increase in cardiac output
d. Decrease in mean arterial pressure

ANS: C
Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and
mean arterial pressure, thereby improving tissue perfusion and oxygenation. Tachycardia is
not a desired response but often occurs as a side effect.
REF: p. 818
Expected Actions/Outcomes) MSC:
Integrated Process: Nursing Process (Evaluation)
7. The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what
is the priority intervention for this client?

Administer an aminoglycoside.
Initiate a dopamine hydrochloride (Intropin) drip.
Administer crystalloid fluids.
Initiate an intravenous heparin drip.
a.
b.
c.
d.
ANS: C
IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. A
dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids.
Aminoglycosides and heparin are given to clients with septic shock.
REF: N/A
MSC: Integrated Process: Nursing Process (Evaluation)
8. The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client
who has shock. Which nursing intervention is a priority when administering this medication?
Ask if the client has chest pain every 30 minutes.
Assess the clients blood pressure every 15 minutes.
Monitor the clients urinary output every hour.
Observe the clients extremities every 4 hours.
a.
b.
c.
d.
ANS: B
The client receiving sodium nitroprusside should have his or her blood pressure assessed
every 15 minutes. Higher doses can cause systemic vasodilation and can increase shock. The
nurse should monitor the clients pain, urinary output, and extremities, but these assessments
do not directly relate to the nitroprusside infusion.
REF: N/A
Integrated Process: Nursing Process (Evaluation)
9. The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which
important action related to the administration of this drug does the nurse implement?
a. Assess the clients respiratory rate.
b. Administer the medication with gravity tubing.
c. Protect the medication from light with an opaque bag.
d. Monitor for hypertensive crisis.
ANS: C
Sodium nitroprusside (Nipride) must be protected from light to prevent degradation of the
drug. It should be delivered via pump. This medication does not have any effect on respiratory
rate. Hypertension is a sign of milrinone (Primacor) overdose.
REF: N/A
10. The nurse is caring for a client who has had an anaphylactic event. Which priority question
does the nurse ask to determine whether the client is experiencing distributive shock?
Is your blood pressure higher than usual?
Are you having pain in your throat?
Have you been vomiting?
Are you usually this swollen?
a.
b.
c.
d.
ANS: D
Anaphylaxis damages cells and causes release of large amounts of histamine and other
inflammatory chemicals. This results in massive blood vessel dilation and increased capillary
leak, which manifests as swelling. The other clinical manifestations do not relate to
anaphylaxis or distributive shock.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
11. A client who has septic shock is admitted to the hospital. What priority intervention does the
nurse implement first?

Obtain two sets of blood cultures.
Administer the prescribed IV vancomycin (Vancocin).
Obtain central venous pressure (CVP) measurements.
Administer the prescribed IV norepinephrine (Levophed).
a.
b.
c.
d.
ANS: A
Blood cultures should be obtained before IV antibiotics are started. If hypotension occurs,
fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if
hypotension persists.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical
Emergencies)
12. The nurse is assessing a client who was admitted for treatment of shock. Which manifestation
indicates that the clients shock is caused by sepsis?

Hypotension
Pale clammy skin
Anxiety and confusion
Oozing of blood at the IV site
a.
b.
c.
d.
ANS: D
The late phase of sepsis-induced distributive shock is characterized by most of the same
cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of
ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed
spontaneously. The other manifestations are associated with all types of shock.
REF: N/A
13. A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that
the clients systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly.
Which intervention does the nurse do first?
a. Insert a Foley catheter to monitor urine output closely.
b. Ask the clients family to come to the hospital because death is near.
c. Initiate the prescribed dobutamine (Dobutrex) intravenous drip.
d. Obtain blood cultures before administering the next dose of antibiotics.
ANS: C
The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output,
systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain
blood pressure and cardiac output. Accurate urinary output and blood cultures are important to
the treatment but are not the priority when a clients pulse pressure is decreasing rapidly. The
family should be updated appropriately.
REF: N/A
Integrated Process: Nursing Process (Analysis)
14. The nurse is assessing clients in the emergency department. Which client is at highest risk for
developing septic shock?

25-year-old man who has irritable bowel syndrome
37-year-old woman who is 20% above ideal body weight
68-year-old woman who is being treated with chemotherapy
82-year-old man taking beta blockers for hypertension
a.
b.
c.
d.
ANS: C
Certain conditions or treatments that cause immune suppression, such as having cancer and
being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a
person to septic shock. The other client situations do not increase the clients risk for septic
shock.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
15. The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication
does the nurse expect to be prescribed?

a. Heparin sodium
b. Vitamin K
c. Corticosteroids
d. Hetastarch (Hespan)
ANS: A
During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade,
clients begin to form numerous small clots. Heparin is administered to limit clotting and
prevent consumption of clotting factors. The other medications would not be prescribed
during the hyperdynamic phase of septic shock.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy
Expected Actions/Outcomes)
16. The nurse is planning care for a client with late-phase septic shock. All of the following
treatments have been prescribed. Which prescription does the nurse question?
Enoxaparin (Lovenox) 40 mg subcutaneous twice daily
Transfusion of 2 units of fresh frozen plasma
Regular insulin intravenous drip per protocol
Cefazolin (Ancef) 1 g IV every 6 hours
a.
b.
c.
d.
ANS: A
Therapy during the second (late) phase of septic shock is aimed at enhancing the bloods
ability to clot. Enoxaparin would increase the clients risk of bleeding and therefore should not
be administered during the last phase of septic shock. Administering clotting factors, plasma,
platelets, and other blood products will assist the clients blood to clot. Intravenous insulin to
control hyperglycemia and antibiotic therapy would continue in the late phases of septic
shock.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy
Expected Actions/Outcomes)
17. The nurse is assessing a client at risk for shock. The clients systolic blood pressure is 20 mm
Hg lower than baseline. Which intervention does the nurse perform first?
Increase the IV fluid rate.
Administer oxygen.
Notify the health care provider.
Place the client in high Fowlers position.
a.
b.
c.
d.
ANS: B
Administration of oxygen for any type of shock is appropriate to help reduce potential damage
from tissue hypoxia. The other interventions should be completed after oxygen is
administered.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Establishing Priorities)
18. A client recovering from septic shock is preparing for discharge home. What priority
information does the nurse include in the teaching plan for this client?
a.
b.
c.
d.
Clean your toothbrush with laundry bleach daily.

Bathe every other day with antimicrobial soap.
Wash your hands after changing pet litter boxes.
Use an electric razor when you shave your face.
ANS: A
The client at risk for septic shock should be instructed to clean his or her toothbrush daily,
either by running it through the dishwasher or by rinsing it in laundry bleach. Clients should
be instructed to bathe daily and wash the armpits, the groin, and the rectal area. The client
should refrain from cleaning pet litter boxes. Clients recovering from septic shock are not at
higher risk for bleeding disorders.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
19. The nurse is providing community education for clients at risk for dehydration. One client
states, We are not at risk because we live in a hot and dry climate. What is the nurses best
response?
a. You are still at risk but not as high a risk as those who live in hot and humid
climates.
b. Any type of heat can cause peripheral vasoconstriction, which causes the body to
lose water.
c. In a hot and dry environment, the body can lose an increased amount of water
without your knowledge.
d. Even though you are not at risk, you should drink adequate fluids when you
exercise.
ANS: C
Teach everyone to prevent dehydration by having adequate fluid intake during exercise or
when in a hot and dry environment. Insensitive water loss increases in this type of
environment. Heat causes vasodilation as well, also contributing to water loss. The other
statements are not accurate.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
20. The emergency department nurse is triaging clients. Which client does the nurse assess most
carefully for hypovolemic shock?

15-year-old adolescent who plays high school basketball
24-year-old computer specialist who has bulimia
48-year-old truck driver who has a 40-pack-year history of smoking
62-year-old business executive who travels frequently
a.
b.
c.
d.
ANS: B
Hypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk
for dehydration owing to excessive vomiting. Basketball, smoking, and traveling do not put
the client at risk for hypovolemic shock.
REF: N/A

21. The nurse is planning discharge education for a client who had an exploratory laparotomy.
Which nursing statement is appropriate when teaching the client to monitor for early signs of
shock?
a. Monitor how much urine you void and report a decrease in the amount.
b. Take your temperature daily and report any below-normal body temperatures.
c. Assess your radial pulse every day and report an irregular rhythm.
d. Monitor your bowel movements and report ongoing constipation or diarrhea.
ANS: A
A decrease in urine output is a sensitive indicator of early shock. In severe shock, urine output
is decreased (compared with fluid intake) or even absent. Alterations in temperature, irregular
rhythms, and changes in bowel movements are not early signs of shock.
REF: N/A
22. A client who has a local infection of the right forearm is being discharged. The nurse teaches
the client to seek immediate medical attention if which complication occurs?

Dizziness on changing position
Increased urine output
Warmth and redness at site
Low-grade temperature
a.
b.
c.
d.
ANS: A
When a local infection becomes systemic, the client develops a high-grade temperature,
decreased urine output, and increased respiratory rate. Because of tachycardia and low blood
pressure, the client may exhibit orthostatic hypotension. This is a subtle sign of systemic
infection that requires further evaluation by the health care provider. The other signs are not
manifestations of complications. Warmth and redness are expected with local infection.
REF: N/A
23. The intensive care nurse is caring for an intubated client who has severe sepsis that led to
acute respiratory distress. Which nursing intervention is most appropriate during this stage of
sepsis?
a. Check blood glucose levels every 4 hours.
b. Monitor intake and urinary output twice each shift.
c. Decrease ventilator rate and tidal volume.
d. Administer prescribed low-dose corticosteroids.
ANS: D
During severe sepsis, interventions should focus on decreasing hypoxia, maintaining acidbase balance, keeping blood glucose levels as normal as possible, maintaining organ
perfusion, minimizing adrenal insufficiency, and decreasing microemboli. Treatment should
include administration of low-dose corticosteroids, insulin drip with blood glucose checks
every 1 to 2 hours, hourly intake and output monitoring, and an increase in ventilator rate and
tidal volume.

REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
MSC: Integrated Process: Nursing Process (Intervention)
24. The nurse is assessing a client who has septic shock. The following assessment data were
collected:
Baseline Data
Todays Data
Heart rate
75 beats/min
98 beats/min
Blood pressure
125/65 mm Hg
128/75 mm Hg
Respiratory rate
12 breaths/min
18 breaths/min
Urinary output
40 mL/hr
40 mL/hr
The nurse correlates these findings with which stage of shock?
a. Early
b. Compensatory
c. Intermediate
d. Refractory
ANS: A
An increase in heart and respiratory rates (heart rate first) from the clients baseline and a
slight increase in diastolic blood pressure may be the only objective manifestations of early
shock. These findings do not correlate with other stages of shock.
REF: N/A
MSC: Integrated Process: Nursing Process (Analysis)
MULTIPLE RESPONSE
1. The nurse is assessing a client who is in early stages of hypovolemic shock. Which
manifestations does the nurse expect? (Select all that apply.)

Elevated heart rate
Elevated diastolic blood pressure
Decreased body temperature
Elevated respiratory rate
Decreased pulse rate
a.
b.
c.
d.
e.
ANS: A, B, D
Heart and respiratory rates increased from the clients baseline level and a slight increase in
diastolic blood pressure may be the only objective manifestations of this early stage of shock.
DIF: Cognitive Level: Knowledge/Remembering
REF: p. 813
2. The nurse is providing health education to a client on immunosuppressant therapy. Which
instructions does the nurse include in this clients teaching? (Select all that apply.)
Wear a facemask at all times.
Take your temperature once a day.
Drink only bottled water.
Avoid any contact with pets.
a.
b.
c.
d.
e. Wash dishes with hot sudsy water.

f. Rinse your toothbrush in liquid laundry bleach.
ANS: B, E, F
Daily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing
toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune
compromised client. Clients at increased risk because of immune suppression need to wear a
facemask when in large crowds or around ill people. Water need not be bottled but should not
be used if it has been standing for longer than 15 minutes. This population is not restricted
from pets but is only advised not to change pet litter boxes.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
3. A client has septic shock. Which hemodynamic parameters does the nurse correlate with this
type of shock? (Select all that apply.)

a. Decreased cardiac output
b. Increased cardiac output
c. Increased blood glucose
d. Decreased blood glucose
e. Increased serum lactate
f. Decreased serum lactate
ANS: A, C, E
Septic shock manifests with decreased cardiac output, increased blood glucose, and increased
serum lactate. The other parameters do not correlate with septic shock.
REF: Table 39-5, p. 823

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Chapter 39: Care of Patients with Shock

condition is at highest risk for distributive shock?

that the client is at risk for acidosis?

fluid replacement. Which fluid does the nurse prepare to administer?

hydrochloride (Intropin) drip. Which manifestation is a desired response to this medication?

d. Decrease in mean arterial pressure

is the priority intervention for this client?

nurse implement first?

indicates that the clients shock is caused by sepsis?

developing septic shock?

does the nurse expect to be prescribed?

Clean your toothbrush with laundry bleach daily.

carefully for hypovolemic shock?

MSC: Integrated Process: Nursing Process (Assessment)

the client to seek immediate medical attention if which complication occurs?

DIF: Cognitive Level: Application/Applying or higher

manifestations does the nurse expect? (Select all that apply.)

e. Wash dishes with hot sudsy water.

type of shock? (Select all that apply.)

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