Which findings would the nurse expect in a patient with early hypovolemic shock?

1. A patient who 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?

   Inhaltsverzeichnis Show

   • Which of the following assessment findings is an early indication of hypovolemic shock?
   • Which assessment findings indicate that a patient is experiencing hypovolemic shock?
   • What will the nurse identify as symptoms of hypovolemic shock?
   • What is the earliest indicator of 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)

   ANS:     B

   When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor.

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

   ANS:    A

   When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of early shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor.

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

   • ANS:    D
   • When cells are deprived of oxygen, they shift to anaerobic metabolism, resulting in the production of lactic acid. Unless the lactic acid is removed from the bloodstream, the blood will become increasingly acidic, resulting in metabolic acidosis. A. Inadequate ventilation leads to respiratory acidosis as CO2 levels rise. B. Hyperventilation leads to respiratory alkalosis as CO2 levels decrease. C. Aerobic metabolism is normal.

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.

   • ANS:     C
   • Collecting data is the first step in critically thinking about a situation. In this case, the urine output is lower than normal, which could be due to several reasons. The initial action of the nurse should be to inspect the urinary catheter system for proper functioning. If the catheter system is inhibiting urine output, then that issue must be addressed to correct the situation. Other interventions will not help if the system is the cause. A. Catheter irrigation is invasive and breaks the sterile system. B. Oral fluids will not help if the system is kinked; also the patient is confused and so may not be able to take oral fluids safely, and an IV is infusing to hydrate the patient. D. An order is needed to increase the IV 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

   ANS:     B

   Stimulation of the renin-angiotensin-aldosterone system from decreased cardiac output causes vasoconstriction and retention of sodium and water to decrease further fluid loss, resulting in oliguria.

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.

   ANS:   AThe priority is to assess the patient in shock quickly, starting with the Cs: airway, breathing, circulation, and disability

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

   ANS:     B

   When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output to deliver adequate oxygen to the tissues by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor.

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.

   ANS:     C

   Because blood is shunted away from the kidneys early in shock to save fluid and provide oxygen to vital organs, the kidneys commonly are injured first. The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Urine output should be monitored for reduction to detect injury. Pupils that are equally reactive to light are normal. Bowel sounds typically remain hypoactive after surgery. Acidosis is expected with shock, and a pH within normal limits is normal.

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

   ANS:    D

   The liver may be injured both by ischemia and by toxins created by the shock state as blood is circulated through it for cleansing. Signs and symptoms of liver injury include decreased production of plasma proteins; abnormal clotting, because clotting factor production by the liver is impaired; and elevated serum levels of ammonia, bilirubin, and liver enzymes.

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

    ANS:     B

    Signs and symptoms of liver injury include abnormal clotting because clotting factor production by the liver is impaired, so the nurse monitors for coagulation disorders such as disseminated intravascular coagulation.

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.”

    ANS:     B

    Shock is defined as inadequate tissue perfusion, in which there is insufficient delivery of oxygen and nutrients to the body’s tissues and inadequate removal of waste products from these tissues.

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.

    ANS:     B

    Patients may have symptoms including wheezing, laryngeal edema, angioedema, and severe bronchospasm, which make it essential for the nurse to ensure a patent airway first. The other actions may be done but are a lower priority than a patent airway.

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

    d.

    Increased oxygen demand

    ANS:     C

    Pain, anxiety, and cold all increase tissue demands for blood and oxygen, which places increased workload on the heart to supply it.

14. The nurse is caring for a patient in mild shock. Which of the following medications should the nurse question if ordered for a patient experiencing shock?

    a.

    Benadryl

    b.

    Solu-medrol

    c.

    Morphine

    d.

    Dopamine

    ANS:     C

    Decreased afterload occurs from vasodilation that occurs from morphine. Shock is characterized by hypotension, so any drug such as morphine that decreases blood pressure should be avoided or used cautiously. Benadryl, Solu-medrol, and Dopamine are all medications used to treat shock.

15. The patient is started on a dopamine infusion for shock. The nurse would expect to see which of the following findings due to the dopamine?

    a.

    Increased respiratory rate

    b.

    Increased blood pressure

    c.

    Decreased heart rate

    d.

    Pain relief

    ANS:     B

    Dopamine strengthens myocardial contraction, increases systolic blood pressure, and increases cardiac output.

16. A patient presents with suspected septic shock. Which of the following actions should the nurse take first?

    a.

    Reassure the patient that everything possible will be done.

    b.

    Insert an angiocath.

    c.

    Obtain patient temperature.

    d.

    Determine if the patient has any medication allergies.

    ANS:     B

    After ensuring a patent airway, the priority treatment interventions are providing cardiovascular support to maintain systolic blood pressure at least at 90 mm Hg. IV access is critical to provide fluids first and then antibiotics. Reassuring the patient is not the first priority. Septic shock is related to infection, so obtaining a temperature and determining medication allergies, as antibiotics will be given, will take place after the IV is started.

17. A patient who had vascular leg surgery is found standing in a large pool of blood flowing from the surgical site. The patient is assisted into bed and is found to be pale with a palpable pulse. What action should the nurse take?

    a.

    Apply oxygen at 2 L/min via nasal cannula.

    b.

    Elevate legs and apply pressure over the bleeding site.

    c.

    Start an infusion of 0.9% NaCl.

    d.

    Notify the registered nurse.

    ANS:     B

    The first priority is to control the bleeding with direct pressure. Elevating the legs will also help. The RN should be notified while the bleeding is being controlled by calling for assistance. Oxygen and IV fluids may be ordered but require a physician’s order.

18. A patient who is found hemorrhaging from an incision has a blood pressure of 70/0 mm Hg. What type of fluid replacement does the nurse anticipate will be ordered initially?

    a.

    Fresh frozen plasma

    b.

    Packed red blood cells

    c.

    0.9 % normal saline

    d.

    Lactated Ringer’s with 50 mL albumin

    ANS:     C

    An isotonic solution such as 0.9% normal saline will be given immediately to restore fluid volume. Then, packed RBCs will be considered based on the patient’s status and need to replace the lost blood.

19. The nurse discovers a patient who is experiencing respiratory distress and mild shock. In which of the following positions should the patient be placed?

    a.

    Semi-Fowler’s position

    b.

    High Fowler’s position

    c.

    Flat with elevated foot of bed

    d.

    Trendelenburg position

    ANS:    A

20. Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday, report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which of these orders should the nurse question?

    a.

    Electrocardiogram (ECG) STAT

    b.

    500 mL 0.9% NS over 30 minutes

    c.

    Arterial blood gases (ABGs) STAT and repeat in 1 hour

    d.

    Oxygen 2 L/min via nasal cannula

    ANS:     B

    The patient data indicate possible cardiogenic shock. This means that any fluid given may overwhelm the heart, which could lead to death. So, the nurse should question IV orders for a cardiogenic shock patient. An ECG, ABGs, or oxygen would be appropriate orders.

21. A patient with a history of a myocardial infarction has chest pain. The patient’s skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take?

    a.

    Place the patient supine.

    b.

    Infuse 0.9% normal saline wide open.

    c.

    Notify the registered nurse.

    d.

    Check the urine specific gravity.

    • ANS:     C
    • The nurse needs the physician to be informed so orders can be received to aid the critically ill patient. A and B are contraindicated for this patient, who may have cardiogenic shock as increased fluid could overwhelm the heart. Sitting up reduces fluid return to the heart and eases breathing. D. Urine specific gravity is used to determine fluid volume status and is not needed for this patient.

22. The nurse discovers a patient after surgery who is hemorrhaging from the incisional site. What is the most important action the nurse should take?

    a.

    Apply pressure to the bleeding site.

    b.

    Offer oral fluids.

    c.

    Warm the patient.

    d.

    Relieve the patient’s apprehension.

    ANS:    A

    The first priority is to control the bleeding with direct pressure. The other options may be considered but are not the first priority.

23. A patient who had surgery 3 days ago has a temperature of 98°F (36.6°C), blood pressure 82/72 mm Hg, pulse 120 beats/minute, and respirations 30/minute. Which of these types of shock does the nurse recognize is likely occurring?

    a.

    Cardiogenic

    b.

    Hypovolemic

    c.

    Neurogenic

    d.

    Septic

    ANS:    D

    During the early, or warm, phase of septic shock, blood pressure, urine output, and neck vein size may be normal, but the skin is warm and flushed. Fever is present in the majority of patients, although some may have a subnormal temperature. Septic shock progresses to a second phase with signs and symptoms similar to hypovolemic shock: hypotension; oliguria; tachycardia; tachypnea; flat jugular and peripheral veins; and cold, clammy skin. Body temperature may be normal or subnormal.

24. The nurse obtains vital signs on a patient with gastrointestinal bleeding who has a large, dark red, foul-smelling stool. Which of these vital sign changes should the nurse report as indicative of early shock?

    a.

    Decreasing systolic blood pressure, bradycardia, and slow respirations

    b.

    Rise in diastolic blood pressure, bradycardia, and slow respirations

    c.

    Drop in diastolic blood pressure, bradycardia, and shallow respirations

    d.

    Normal blood pressure, tachycardia, and rapid respirations

    ANS:    D

    Normal blood pressure, tachycardia, and rapid respirations occur in mild shock due to compensatory mechanisms. As shock progresses and compensatory mechanisms begin to fail, vital signs decrease.

25. A patient is transferred to the intensive care unit in neurogenic shock. The patient’s wife asks what is happening. Which of these responses should the nurse give?

    a.

    “Your husband’s heart has failed as a pump that moves blood around the body.”

    b.

    “Your husband’s blood vessels have dilated and lowered his blood pressure.”

    c.

    “Your husband has decreased circulating blood volume.”

    d.

    “Your husband is having an allergic reaction.”

    ANS:   B

    Neurogenic shock is a form of distributive shock in which massive vasodilation of the peripheral circulation occurs, causing hypotension.

26. The nurse would recognize anaphylactic, septic, and neurogenic shock as examples of what type of shock?

    a.

    Cardiogenic

    b.

    Distributive

    c.

    Hypovolemic

    d.

    Obstructive

    ANS:     B

    Subcategories of distributive shock include anaphylactic, septic, and neurogenic shock.

27. The metabolic acidosis of shock is caused by which of these mechanisms?

    a.

    Decreased anaerobic metabolism

    b.

    Release of cortisol and glucagons

    c.

    Excessive aerobic metabolism

    d.

    Excessive anaerobic metabolism

    ANS:    D

    Anaerobic metabolism results in the production of lactic acid as an unwanted by-product. Unless the lactic acid can be circulated to the liver and thus removed from the bloodstream, the blood will become increasingly acidic.

28. The nurse is contributing to a staff education program about complications associated with urinary catheters. Which of the following types of shock should the nurse recommend be included in the presentation?

    a.

    Anaphylactic

    b.

    Cardiogenic

    c.

    Hypovolemic

    d.

    Septic

    ANS:    D

29. As part of ongoing data collection and care of a patient in shock, the nurse notes a slowing heart rate, systolic blood pressure less than 60 mm Hg, a decreasing temperature, decreasing respiration rate, and scant urine output. These signs and symptoms indicate to the nurse that the patient is in which stage of shock?

    a.

    Mild

    b.

    Compensated

    c.

    Moderate

    d.

    Severe

    ANS:    D

    Severe irreversible/decompensated shock symptoms include slowing heart rate, systolic blood pressure less than 60 mm Hg, decreasing temperature, decreasing respiration rate, and almost no urine output as compensation mechanisms have failed and death is imminent.

30. The nurse would recognize cardiogenic shock from other types of shock by the data collection findings for which of the following?

    a.

    Bronchospasm

    b.

    Oliguria

    c.

    Pulmonary edema

    d.

    Tachypnea

    ANS:     C

    The presence of pulmonary edema is what differentiates cardiogenic shock from other forms of shock.

31. Which one of the following nursing diagnoses would be most appropriate for the nurse to recommend be included in the patient’s plan of care for a patient in shock?

    a.

    Excess fluid volume

    b.

    Hopelessness

    c.

    Inadequate tissue perfusion

    d.

    Risk for aspiration

    ANS:     C

    Inadequate tissue perfusion (renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) related to hypovolemia or inadequate cardiac output or inadequate vascular tone is the most appropriate nursing diagnosis.

32. The nurse receives an assignment of patients. Which of the following patients should the nurse observe first?

    a.

    A patient with sickle cell anemia who is receiving a monthly transfusion of a unit of packed red blood cells who is reporting left knee pain

    b.

    A patient with diabetes who has a blood sugar of 85 and is eating lunch

    c.

    A patient with cellulitis who is receiving the first dose of intravenous antibiotics and who is reporting a feeling of tightness in the throat

    d.

    A patient who has a pressure ulcer who is due for a dressing change

    • ANS:     C
    • The patient may be having an allergic reaction and requires immediate attention to intervene as anaphylactic shock may occur. A, B, D. There are no abnormalities occurring that require immediate intervention.

33. The nurse is monitoring a patient who has been treated for several days for septic shock after surgery. Which of the following findings indicate that the patient is improving? (Select all that apply.)

    a.

    Urine output less than 25 mL/hr

    b.

    SpO2 94%

    c.

    Blood pressure 110/90 mm Hg

    d.

    Pulse 75 beats/minute

    e.

    Temperature 101°F (38.3°C)

    f.

    pH is 7.33

    ANS: B, C, D

    B, C, and D indicate vital signs within normal limits that show improvement. A. Urine output should be 30 mL/hr to be normal. E. Normal temperature is 98.6°F (37°C). F. pH below 7.35 is abnormal and indicative of ongoing acidosis related to shock.

34. The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which of the following diagnostic tests would the nurse expect? (Select all that apply.)

    a.

    Complete blood count

    b.

    Chest x-ray

    c.

    Electroencephalogram (EEG)

    d.

    Blood type and crossmatch

    e.

    Arterial blood gas

    f.

    Urinalysis

    ANS: A, B, D, E, F

    Complete blood count, chest x-ray, blood typing and crossmatch, arterial blood gases, and urinalysis are diagnostic tests done in the assessment of shock. EEG would not be done.

35. The nurse is caring for a patient experiencing shock who is taking Atenolol (Tenormin). Which of the following symptoms of shock would be expected to be present in this patient? (Select all that apply.)

    a.

    Pulse 115 beats per minute

    b.

    Respirations 28 per minute

    c.

    Blood pressure 88/48 mm Hg

    d.

    Capillary refill greater than 3 seconds

    • ANS:    A
    • The sympathetic nervous system is activated in shock so respirations increase. C. Blood pressure drops in shock. D. Prolonged capillary refill is expected in shock due to decreased blood pressure and vasoconstriction from sympathetic nervous system response. A. Tachycardia will not be present as expected with sympathetic nervous system activation. Beta blockers block the response of the sympathetic nervous system, which is activated in shock.

36. Which of the following occurs as the body’s sympathetic nervous system responds to falling blood pressure? (Select all that apply.)

    a.

    Blood is shunted away from the skin, kidneys, and intestines.

    b.

    Vasodilation leads to increased fluid loss.

    c.

    Blood glucose levels increase.

    d.

    Sodium and water are retained.

    e.

    Less oxygen is delivered to tissues.

    f.

    Epinephrine is released from the adrenal medulla.

    • ANS: A, C, D, F
    • As a compensatory mechanism (fight or flight), blood is shunted away from the skin, kidneys, and intestines to supply the major organs. C. Blood glucose levels increase for energy. D. Sodium and water are retained to ensure adequate fluid volume. F. Epinephrine is released from the adrenal medulla to stimulate increased cardiac output. B, E. Vasoconstriction occurs, and the goal is to increase oxygen delivered to the tissues.

37. The nurse is caring for a patient in shock and explains procedures and treatment to the patient. The nurse provides these explanations for which of the following reasons? (Select all that apply.)

    a.

    To reduce the signs of shock

    b.

    To provide support

    c.

    Prevent future shock episodes

    d.

    Knowledge decreases anxiety

    ANS: B, D

    A patient in shock is acutely ill and experiencing anxiety. Keeping the patient informed as able will help reduce anxiety and provide support as treatment plans are shared.

38. Which of the following signs and symptoms would the nurse expect to see for a patient going into anaphylactic shock? (Select all that apply.)

    a.

    Urticaria

    b.

    Polyuria

    c.

    Laryngeal edema

    d.

    Bronchospasm

    ANS:   A, C, D

    Anaphylactic shock symptoms include urticaria, pruritus, wheezing, laryngeal edema, angioedema, and severe bronchospasm. Decreased urine rather than increased urination would be seen in a patient in shock.

39. The nurse is monitoring a patient who has been in prolonged shock. For which of the following serious complications would the nurse observe to report? (Select all that apply.)

    a.

    Malnutrition

    b.

    Adult respiratory distress syndrome

    c.

    Diabetes mellitus

    d.

    Multiple organ dysfunction syndrome

    e.

    Cerebrovascular accident

    f.

    Sepsis

    ANS: B, D

    Acute respiratory distress syndrome, disseminated intravascular coagulation, and multiple organ dysfunction syndrome are three serious conditions that may follow a prolonged episode of shock.

40. The nurse is monitoring hourly urine output on a patient who has a urinary catheter inserted. The nurse understands that the kidneys can tolerate reduced blood flow for about ____________________ hour(s) before permanent damage occurs, which can be exhibited by reduced urine output that would need to be reported.

    ANS:

    1

    The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Cells in the kidneys die when there is a lack of oxygen and nutrients. If there is widespread damage to the kidneys, complete renal failure is likely.

41. A patient who is a full code status is found unresponsive. The nurse immediately begins CPR with the understanding that brain cells die when the brain is deprived of oxygen for more than ____________________ minute(s).

    ANS:

    4

    MODS is a major cause of death following shock. It usually begins with respiratory failure, followed by failure of the kidneys, heart, liver, cerebral, and gastrointestinal function.

Which of the following assessment findings is an early indication of hypovolemic shock?

Which assessment findings indicate that a patient is experiencing hypovolemic shock?

What will the nurse identify as symptoms of hypovolemic shock?

What is the earliest indicator of shock?