Question 1

While caring for a patient in the post-anesthesia care unit (PACU) Who has developed Hypovolemic shock, a nurse should position the patient?

Accepted Answer

Answer reason: Laying the client supine and elevating the legs (modified Trendelenburg/passive leg raise concept) transiently recruits venous blood from the lower extremities to the central circulation without the downsides of head-down tilt. Trendelenburg can worsen respiratory mechanics and increase aspiration risk in a post-anesthesia patient, while also not reliably improving perfusion. Elevating the head of bed 45° reduces venous return and can worsen hypotension, and completely flat is less effective than leg elevation for augmenting preload.

Question 2

The nurse is caring for a client who just returned from the recovery room after undergoing abdominal surgery. The nurse would monitor for which early sign of hypovolemic shock?

Accepted Answer

Answer reason: Tachycardia is one of the earliest, most sensitive hemodynamic indicators of acute volume loss, especially post-op where bleeding is a key risk. Changes like altered mental status (e.g., sleepiness) are typically later findings as cerebral perfusion worsens or may reflect residual anesthesia rather than shock. Increased depth of respirations can occur with metabolic acidosis later, and “increased orientation” is not consistent with developing hypoperfusion.

Question 3

A nurse is assisting with the care of a preschooler who is postoperative following tetralogy of Fallot correction. Which of the following manifestations indicates the child is possibly experiencing decreased cardiac output?

Accepted Answer

Answer reason: After cardiac surgery, this finding is concerning for impaired hemodynamics and warrants prompt assessment of perfusion and vital signs. In contrast, warm extremities and a capillary refill of 2 seconds suggest adequate peripheral perfusion rather than low output. A blood pressure of 112/66 mm Hg alone does not indicate decreased output and can remain normal early due to compensatory vasoconstriction and tachycardia.

Question 4

The nurse is assessing a septic patient with hypotension and tachycardia. The nurse reviews the patient's lab results and expects an elevation of?

Accepted Answer

Answer reason: Sepsis with hypotension and tachycardia suggests systemic hypoperfusion and impaired oxygen delivery at the tissue level, leading to anaerobic metabolism. This increases serum lactate, which is used clinically to screen for severity and monitor response to resuscitation in septic shock. Ammonia elevation is more characteristic of hepatic failure, not the expected primary lab change in early sepsis-related shock. Platelets more often decrease in severe sepsis due to consumption/DIC, and troponin can rise from demand ischemia but is not the most expected hallmark lab elevation for septic hypoperfusion.

Question 5

Which finding would make you suspect that your patient might be in cardiogenic shock?

Accepted Answer

Answer reason: Cardiogenic shock is pump failure leading to low stroke volume, reduced forward flow, and signs of poor perfusion, so bedside findings typically reflect decreased effective cardiac function. Decreased heart sounds can be seen with markedly reduced contractility and low cardiac output states, supporting concern for cardiogenic shock when paired with hypotension and cool, clammy skin. By contrast, a cardiac index greater than 2.2 L/min is generally within/above the minimum acceptable range and argues against cardiogenic shock. Bounding pulses and increased cardiac output are more consistent with hyperdynamic states (e.g., early septic shock) rather than cardiogenic pump failure.

Question 6

The recovery room nurse is caring for a client who has just had a left BKA. The client's surgical dressing is saturated with blood, the apical pulse is elevated, and the blood pressure is decreased. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: The priority is immediate hemorrhage control to stabilize circulation in a postoperative client showing signs of hypovolemia (saturated dressing, tachycardia, hypotension). Reinforcing the existing dressing applies added pressure without disrupting a forming clot, which can reduce ongoing bleeding and buy critical time. Removing or frequently changing the dressing can worsen bleeding by dislodging clots, so adding gauze is the safest immediate bedside action. After reinforcing and assessing for continued heavy bleeding, escalation (e.g., notifying the surgeon) is indicated; a tourniquet is not a routine first-line nursing action post-op due to ischemia risk and typically requires specific orders/protocols.

Question 7

A woman delivers her baby immediately on arrival at the emergency department and 5 minutes later delivers the placenta. The nurse's assessment is that the woman's uterus is boggy and midline. What action should the nurse take first?

Accepted Answer

Answer reason: A boggy uterus immediately postpartum indicates uterine atony, the leading cause of early postpartum hemorrhage, and the priority is to restore uterine tone quickly to reduce bleeding. Fundal massage is the fastest initial nursing action to stimulate uterine contraction and firm the uterus while simultaneously assessing ongoing blood loss. Oxytocin is appropriate but is typically given after or alongside initial manual measures rather than delaying immediate mechanical stimulation. Having the woman void is most critical when the uterus is boggy and displaced (often to the side) from bladder distention; here it is midline, so bladder distention is less likely to be the primary cause.

Question 8

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority?

Accepted Answer

Answer reason: The immediate nursing priority is to support circulation and perfusion, and rapid isotonic fluid administration helps improve preload while the team prepares for additional measures (e.g., vasopressors) if needed. Assessments for hematuria or bowel issues do not address the life-threatening hemodynamic instability. A focused neurologic exam is important but follows initial stabilization of airway/breathing/circulation when perfusion is critically compromised.

Question 9

The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially?

Accepted Answer

Answer reason: In hypovolemic shock, the immediate priority is rapid intravascular volume expansion to restore preload and improve tissue perfusion. An isotonic crystalloid stays primarily in the extracellular space and provides effective initial plasma volume support, making it appropriate for rapid bolus administration. Colloids such as albumin are not first-line for initial resuscitation because they are more costly and typically reserved for select situations after crystalloids or when specific indications exist. Dextrose-containing solutions (including D5W or D5 in LR) are not appropriate for initial shock resuscitation because the dextrose is rapidly metabolized and the remaining free water distributes out of the intravascular space, providing poor immediate volume replacement.

Question 10

The nurse is caring for client with sepsis and acute respiratory failure, who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)?

Accepted Answer

Answer reason: Decreased preload is most likely to present clinically as hypotension, particularly in septic patients who may already have vasodilation and relative hypovolemia. This effect can be worsened by high PEEP or inadequate fluid status. In contrast, increased cardiac output is not an expected adverse effect of PPV because the primary hemodynamic impact is reduced preload.

Question 11

The RN receiving Ms. N on the postpartum unit is aware of her postpartum hemorrhage. What would be the first clinical sign of hypovolemia related to postpartum hemorrhage?

Accepted Answer

Answer reason: In postpartum hemorrhage, blood pressure is often preserved initially due to vasoconstriction and increased heart rate, so hypotension is typically a later finding. Decreased urine output and mental status changes reflect reduced renal and cerebral perfusion, which generally occur after more significant volume loss. Therefore, the earliest clinical indicator of developing hypovolemia is the compensatory rise in pulse rate.

Question 12

A Certified Registered Nurse Anesthetist (CRNA) places an epidural catheter on an obstetric patient and doses it with Ropivacaine. The labor and delivery nurse expects which of the following side effects of epidural anesthesia?

Accepted Answer

Answer reason: This hemodynamic effect makes maternal blood pressure drops one of the most expected and clinically important adverse effects to monitor after dosing. Circumoral numbness is more suggestive of local anesthetic systemic toxicity from intravascular injection, which is less expected with a correctly functioning epidural. Maternal hypotension can secondarily reduce uteroplacental perfusion and contribute to fetal heart rate changes, but the direct and most expected side effect for the nurse is the maternal blood pressure decrease.

Question 13

The nurse notes a change in the condition of a client in septic shock with an infected leg ulcer and positive blood cultures for methicillin-resistant Staphylococcus aureus. Which assessment finding is most important for the nurse to report to the health care provider?

Accepted Answer

Answer reason: New cool, clammy skin suggests peripheral vasoconstriction and progression to a late, decompensated shock state with critically reduced perfusion. This indicates impending or ongoing circulatory failure and can precede severe hypotension, altered mentation, and multi-organ dysfunction, so it is the most urgent change to report. By comparison, an SpO2 of 92% and sinus tachycardia can occur in sepsis and are important but are less specific for sudden deterioration than a finding signaling markedly reduced perfusion.

Question 14

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock?

Accepted Answer

Answer reason: This classically produces hypotension with relative bradycardia rather than tachycardia. Marked bradycardia (48/min) supports this mechanism and helps distinguish it from hypovolemic shock, which typically presents with tachycardia and vasoconstriction. Hypertension is not expected in neurogenic shock, and cool clammy skin suggests catecholamine-mediated vasoconstriction rather than sympathetic loss. Low-grade fever does not best confirm neurogenic shock and may reflect inflammation, infection, or environmental factors.

Question 15

The nurse reading the operative record for a client who had cardiac surgery notes that the client’s cardiac output after surgery was 3.6 L/min. The nurse plans care knowing that this measurement indicates which range?

Accepted Answer

Answer reason: A value of 3.6 L/min is slightly under the usual average but close enough to be considered at the low end of the acceptable/normal range rather than frankly abnormal. This supports monitoring and optimizing preload, afterload, and contractility without assuming severe pump failure based on this number alone. In contrast, labeling it simply “below normal” implies definite pathology, whereas the more accurate interpretation is borderline/low-end normal in context.

Question 16

A nurse is caring for a client who had a vaginal delivery 4 hours ago. The client has saturated a perineal pad in 20 minutes. During assessment, the nurse notices that the client has a boggy uterus that is deviated to the right. Which intervention should the nurse perform first?

Accepted Answer

Answer reason: The fastest first nursing action is to empty the bladder to help the uterus return midline and firm up, thereby reducing bleeding. Oxytocin may be indicated if uterine atony persists, but correcting a likely reversible cause (full bladder) should occur immediately. CBC is diagnostic and does not stop active bleeding, and oxygen is supportive but does not address the primary mechanical contributor to uterine atony in this presentation.

Question 17

The nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

Accepted Answer

Answer reason: Capillary refill is a rapid bedside indicator of peripheral perfusion and therefore reflects whether circulation is improving with resuscitation. Skin turgor and burn-site edema are unreliable because burns cause local tissue injury, inflammation, and third spacing that can distort these findings regardless of circulating volume. The amount of fluid tolerated over 24 hours reflects intake tolerance rather than adequacy of perfusion, and can be misleading when ongoing capillary leak persists early after major burns.

Question 18

A Certified Registered Nurse Anesthetist (CRNA) places an epidural catheter in an obstetric patient and doses it with Ropivacaine. The labor and delivery nurse expects which of the following side effects of epidural anesthesia?

Accepted Answer

Answer reason: This hemodynamic shift commonly produces maternal hypotension and is a key anticipated adverse effect requiring close BP monitoring and interventions (e.g., left uterine displacement, IV fluids, vasopressor per protocol). Circumoral numbness is more consistent with local anesthetic systemic toxicity from intravascular injection rather than an expected epidural effect. Fetal heart rate changes can occur secondary to maternal hypotension, but the primary expected maternal side effect is the drop in blood pressure, not a direct baseline fetal bradycardia effect of the medication.

Question 19

A client is seen following a motor vehicle collision. An intravenous (IV) infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding best alerts the nurse to the development of hypovolemic shock?

Accepted Answer

Answer reason: Urine output

Question 20

An older adult client is admitted to the hospital from a long-term care facility. The nurse establishes a nursing diagnosis of decreased fluid volume related to poor intake and fever. Which symptoms most concern the nurse?

Accepted Answer

Answer reason: The client's temperature is 102°F (38.4°C), pulse is 120 beats per minute, and blood pressure 88/54 mm Hg. Decreased fluid volume threatens tissue perfusion, so signs of hemodynamic instability are the most urgent. Fever increases insensible losses, and tachycardia with hypotension indicates significant volume depletion with possible progression toward hypovolemic shock. This combination reflects impaired circulatory compensation and requires prompt assessment and fluid resuscitation as appropriate. In contrast, orthopnea and dependent edema suggest fluid overload or cardiac failure rather than the stated diagnosis of decreased fluid volume.

Question 21

A client’s electrocardiogram tracing reveals a regular atrial rate, irregular ventricular rate with two PR intervals to each QRS complex. What should the nurse do to help the client?

Accepted Answer

Answer reason: A regular atrial rate with an irregular ventricular response and two PR intervals for each QRS suggests a second-degree AV block with intermittent nonconducted atrial impulses, creating clinically significant bradycardia risk. The key nursing principle is that symptomatic or high-grade conduction blocks often require pacing to maintain adequate cardiac output and prevent progression to complete heart block. Preparing for pacemaker placement aligns with definitive management when conduction through the AV node is unreliable. Defibrillation is reserved for pulseless VT/VF, and synchronized cardioversion targets tachyarrhythmias rather than conduction blocks. Simply observing can delay treatment if perfusion worsens or pauses occur.

Question 22

You are called into a patient's room by a nurse's aid, who states that the patient suddenly complained of feeling weak and nauseous. You obtain a set of vital signs. The patient's blood pressure has decreased from 130/78 to 80/42. What position should you place the patient in prior to notifying the physician?

Accepted Answer

Answer reason: Elevating the legs with the head and torso relatively flat increases venous return to the heart, which can transiently improve preload and blood pressure. This is an appropriate rapid nursing intervention that can be initiated before calling the provider because it addresses ABCs/circulation. Sims’ position is for enemas/rectal procedures and does not optimize perfusion, and lithotomy is used for pelvic exams and may worsen hemodynamic instability.

Question 23

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

Accepted Answer

Answer reason: A boggy uterus in the immediate postpartum period indicates uterine atony, the leading cause of postpartum hemorrhage due to inadequate uterine contraction and poor compression of uterine blood vessels. Immediate fundal massage stimulates uterine muscle contraction to restore tone and reduce bleeding risk. Elevating legs or turning to the left side does not address the primary cause of bleeding in uterine atony. Pushing on the uterus to express clots is unsafe because it can worsen hemorrhage and increase risk of uterine inversion; clots should be managed after uterine tone is restored and bladder is assessed/emptied if needed.

Question 24

Your home health client has been throwing up for several days. You now find her lying in her bed. She is pale, lethargic, and her eyes are dull. She is also anxious. Which of the following is most likely?

Accepted Answer

Answer reason: Prolonged vomiting can cause significant fluid and electrolyte loss, reducing circulating intravascular volume and impairing tissue perfusion. Pallor, lethargy, anxiety/restlessness, and “dull” eyes are consistent with dehydration progressing to hypovolemia and shock physiology. This presentation fits a hemodynamic emergency where compensatory sympathetic activation may initially produce anxiety and poor peripheral perfusion. Congestive heart failure would more typically show fluid overload findings (e.g., edema, crackles) rather than volume depletion after days of emesis. The other options do not directly explain an acute volume-loss picture after prolonged vomiting.

Question 25

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?

Accepted Answer

Answer reason: Confusion signals reduced cerebral perfusion, and urine output of 15 mL in 2 hours suggests critically decreased renal perfusion (shock-level low output). Orthopnea reflects significant pulmonary congestion and impaired oxygenation risk that can rapidly deteriorate. By comparison, mild edema, modest weight gain, or stable vital signs with mild crackles are concerning but do not signal the same degree of imminent organ failure.

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