Medical Surgical 3 Exam Multiple Questions and Answers

Medical Surgical 3 Exam Multiple Questions and Answers 2023/2024 Test Bank Guide

SHOCKS

• Your client in neurogenic shock is not responding to IV fluids. The client is started on vasopressors. What

option below, if found in your client, would indicate the medication is working?

• Decreased CVP (central venous pressure)
• Mean arterial pressure (MAP) 90 mmHg
• Serum lactate 6 mmol/L
• Blood pH 7.20

A MAP of 85-90 mmHg will help maintain tissue perfusion and indicates the vasopressor is working to maintain tissue perfusion. It does this by causing vasoconstriction. Options A, C, and D would indicate tissue perfusion is decreased.

• A client with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse

anticipate will be ordered by the physician STAT?

• Adenosine
• Warfarin
• Atropine
• Norepinephrine

Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body.Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn't working the way it should, it can NOT oppose the parasympathetic system which will take over and lead to bradycardia.

• You're providing care to a client experiencing neurogenic shock due to an injury at T4. As the nurse, you know

which of the following is a client safety priority?

• Keeping the head of the bed greater than 45 degrees at all times.
• Repositioning the client every thirty minutes. c.

Keeping the client's spine immobilized.

• Avoiding log-rolling the client during transport.

It is very important when a client has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the client's spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.

• A 42-year-old male client is admitted with a spinal cord injury. The client is experiencing severe hypotension

and bradycardia. The client is diagnosed with neurogenic shock. Why is hypotension occurring in this client with neurogenic shock?

• The client has an increased systemic vascular resistance. This increases preload and decreases afterload,

which will cause severe hypotension.

• The client's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels

and vasodilation is occurring.

• The client's parasympathetic nervous system is being unopposed by the sympathetic nervous system,

which leads to severe hypotension.

• The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has

led to severe hypotension.

• Which finding is the best indicator that the fluid resuscitation for a 90-kg client with hypovolemic shock has

been effective?

• Hemoglobin is within normal limits.
• Urine output is 65 mL over the past hour.
• Central venous pressure (CVP) is normal.
• Mean arterial pressure (MAP) is 72 mm Hg. 1 / 4

Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

• Which assessment information is most important for the nurse to obtain when evaluating whether

treatment of a client with anaphylactic shock has been effective?

• Heart rate
• Blood pressure
• Orientation
• Oxygen saturation

Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

• When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for clients

experiencing shock, which action by the new RN indicates a need for more education?

• Placing the pulse oximeter on the ear for a client with septic shock
• Keeping the head of the bed flat for a client with hypovolemic shock
• Maintaining a cool room temperature for a client with neurogenic shock
• Increasing the nitroprusside infusion rate for a client with a very high SVR

Clients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

• A client who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which

assessment finding obtained by the nurse indicates a need for immediate action?

• The client’s heart rate is 58 beats/min.
• The client’s extremities are warm and dry. c.

The client’s IV infusion site is cool and pale.

• The client’s urine output is 28 mL over the past hour.

The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

• An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness.

Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take?

• Have the student breathe into a paper bag.
• Notify the physician immediately.
• Obtain an order for an anxiolytic medication.
• Administer supplemental oxygen.

The client is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified.

• If a client has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of volume loss

this client has experienced?

• 25%
• 40%
• 30%
• 10% 2 / 4

This client has lost 40% of blood volume. Based on this amount of fluid loss, this client would be in class III (stage 3 of hypovolemic shock). Class III occurs when volume loss is 30-40% or 1,500-2,000 mL in an adult.

11. A mainstay of therapy for virtually all forms of shock is:

• Intravenous fluids.
• Epinephrine.
• Phenylephrine.
• Red blood cells.

Intravenous fluids. A person experiencing shock may have lost a significant amount of body fluid which needs to be replaced. B, C, and D: These options are not included in the treatment for shock.

• Which of the following medications is least likely to alter the usual presentation of clients presenting with

hypovolemic shock?

• Metoprolol.
• Diltiazem.
• Furosemide.
• Cephalexin.

Cephalexin. Cephalexin is an antibiotic, which could not alter the presentation of a client with hypovolemic shock since it is for infection.A: Metoprolol is a beta-blocker that affects the heart and circulation (blood flow through arteries and veins).B: Diltiazem is a calcium channel blocker. It works by relaxing the muscles of your heart and blood vessels.Diltiazem is used to treat hypertension (high blood pressure), angina (chest pain), and certain heart rhythm disorders.C: Furosemide could greatly alter the usual presentation of a client with hypovolemic shock in a negative way as this drug promotes passage of fluids through the urine.

• As the nurse you know that in order for hypovolemic shock to occur the client would need to lose

of their blood volume.

• <30%
• >25%
• >15%
• >10%

As the nurse you know that in order for hypovolemic shock to occur the client would need to lose 15% or more of their blood volume.

• Which of the following intravenous solutions is least useful, and possibly harmful, as the initial resuscitation

solution in a client with a head injury who has blood loss?

• 5% dextrose in water.
• Normal saline.
• Lactated Ringer’s.
• Hypertonic saline.

Hypertonic saline. Hypertonic saline takes out the water out of the cells which could further lead to dehydration and shock.

A: 5% dextrose in water is seldom used for clients with shock.

B: Normal saline solution could be administered during shock but not as the main IV solution.

C: Lactated Ringer’s is the solution of choice for clients in shock.

• A client who is experiencing hypovolemic shock has decreased cardiac output, which contributes to

ineffective tissue perfusion. The decrease in cardiac output occurs due to?

• An increase in cardiac preload
• An increase in stroke volume
• A decrease in cardiac preload
• A decrease in cardiac contractility 3 / 4

Because there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart (this is the amount of blood draining back to the heart). Hence, this will lead to a DECREASE in preload. Remember preload is the amount the ventricles stretch once their filled with blood. The ventricle won’t be stretching too much because there isn’t enough fluid to fill them. This will decrease stroke volume and in turn decrease cardiac output.

• A client who is in hypovolemic shock has the following clinical signs: Heart rate 120 beats/minute, blood

pressure 80/55 mmHg and urine output 20ml/hr. After administering an IV fluid bolus, which of these signs if noted by the healthcare provider is the best indication of improved perfusion?

• Heart rate drops to 100 beats/minute.
• Right atrial pressure increases.
• Urine output increases to 30mL/hour.
• Systolic blood pressure increases to 85 mmHg.

An increase in the urine output indicates that perfusion is improving. A, B, and D: These options are not indicative of an improved perfusion.

• Nurse Ram, is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for

help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform?

• Removing the stinger by scraping it.
• Applying a cold compress.
• Taking an oral antihistamine.
• Calling the 911.

Removing the stinger by scraping it. Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client.

B&C: After removing the stinger, Antihistamine and cold compress follow.

D: The caller should be further advised about symptoms that require 911 assistances.

• Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a drug should

include which of the following actions first?

• Administering oxygen
• Inserting an I.V. catheter
• Obtaining a complete blood count (CBC)
• Taking vital signs

Administering oxygen Giving oxygen would be the best first action in this case.B: If the client doesn’t already have an I.V. catheter, one may be inserted now if anaphylactic shock is developing.

C: Obtaining a CBC wouldn’t help the emergency situation.

D: Vital signs then should be checked and the physician immediately notified.

• What are some conditions that may precipitate anaphylactic shock?
• Insects.
• Food.
• Medicines.
• All of the above.

All of the above. Insects, food, or medicines could cause anaphylactic shock.A: Insects such as bees and wasps could precipitate anaphylactic shock after biting the victim.B: Food such as peanuts and seafood are some of the most common causes of anaphylactic shock.C: Medicines such as antibiotics gives a high risk of developing anaphylactic shock.

• You’re providing care to a client in anaphylactic shock. What is NOT a typical medical treatment for this

condition, and if ordered the nurse should ask for an order clarification?

• IV Diphenhydramine
• Epinephrine
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