Question 1

Which type of shock is known for decreased intravascular volume resulting from loss of blood or plasma?

Accepted Answer

Answer reason: Shock caused by loss of circulating volume leads to reduced venous return (preload), decreased stroke volume, and lowered cardiac output with inadequate tissue perfusion. Loss of whole blood (hemorrhage) or plasma/fluid (e.g., burns, severe dehydration) directly produces this intravascular volume deficit. Cardiogenic shock is primarily pump failure despite adequate volume, while obstructive shock is due to mechanical blockage of cardiac filling or outflow. Neurogenic shock results from loss of sympathetic tone causing vasodilation rather than primary volume loss.

Question 2

The nurse is caring for a client experiencing cardiac tamponade. The nurse is aware that the client is at highest risk for developing which type of shock?

Accepted Answer

Answer reason: When cardiac output falls, tissue perfusion declines, producing hypotension and signs of shock that clinically aligns most closely with cardiogenic-type low-output shock. The other options are driven by different primary mechanisms: anaphylactic and septic shock are distributive (vasodilation/capillary leak), and hypovolemic shock is due to true intravascular volume loss. Recognizing the hemodynamic problem (impaired filling → low CO) guides urgent interventions such as pericardiocentesis and supportive measures.

Question 3

The nurse determines that a client at risk for the development of cardiogenic shock would present with which of the following?

Accepted Answer

Answer reason: Cardiac index directly quantifies this impaired pump performance and typically falls early as contractility and stroke volume drop. Hypotension, reduced cerebral perfusion, and other end-organ hypoperfusion findings are downstream consequences and may appear later or vary with compensatory vasoconstriction. Bradycardia is not the expected early pattern because sympathetic compensation more commonly produces tachycardia in shock states.

Question 4

The nurse is assessing a client who is displaying the earliest sign of cardiogenic shock. The nurse would document this assessment finding as?

Accepted Answer

Answer reason: Cardiogenic shock causes an abrupt drop in cardiac output, leading to early cerebral hypoperfusion. Subtle restlessness, confusion, or decreased responsiveness can appear before later peripheral signs become obvious. Decreased urine output is a key sign of reduced renal perfusion but typically lags behind early neurologic changes. Cyanosis is a later, more severe manifestation of hypoxemia/poor perfusion, and an S4 reflects decreased ventricular compliance rather than shock severity or earliest shock indicator.

Question 5

The nurse is assessing the client following an inferiorseptal wall MI. Which potential complication should the nurse further explore when noting that the client has JVD and ascites?

Accepted Answer

Answer reason: An inferior (often right coronary artery–related) MI can involve the right ventricle, reducing forward flow to the lungs and causing blood to back up into the venous system. This elevated venous pressure leads to distended neck veins and fluid accumulation in the abdomen. In contrast, left-sided failure more typically presents with pulmonary congestion (crackles, dyspnea, orthopnea) rather than prominent JVD/ascites.

Question 6

A paradoxical pulse occurs in a client who had coronary artery bypass graft (CABG) surgery 2 days ago. Which surgical complication should the nurse suspect?

Accepted Answer

Answer reason: Two days post-CABG, bleeding into the pericardial space can rapidly create this pressure and compromise cardiac output. This hemodynamic pattern aligns with tamponade physiology and is a high-risk postoperative complication requiring urgent recognition and intervention. In contrast, left-sided heart failure more typically causes pulmonary congestion and dyspnea rather than a marked inspiratory fall in systolic pressure. Prompt assessment for accompanying findings (hypotension, muffled heart sounds, JVD) supports the suspicion and escalation of care.

Question 7

Which intervention is recommended postoperatively for a client with a surgical repair of coarctation of the aorta?

Accepted Answer

Answer reason: A rapid-acting titratable vasodilator is used to tightly control blood pressure and reduce afterload. This medication allows minute-to-minute adjustment in an ICU setting to maintain target pressures and protect perfusion. In contrast, an inotrope like dopamine would tend to raise blood pressure/afterload and can worsen hypertension rather than treat it. Fluid boluses are not routine unless hypovolemia is present and may aggravate hypertension or heart failure.

Question 8

Which finding would the nurse anticipate in a 1-year-old child with supraventricular tachycardia?

Accepted Answer

Answer reason: In a 1-year-old, a sustained rate exceeding about 220/min strongly suggests SVT, reflecting a re-entrant tachyarrhythmia rather than physiologic compensation. Such extreme rates shorten diastolic filling time and can quickly reduce cardiac output, so the nurse would anticipate markedly elevated heart rate values. A rate like 180/min can occur with fever, pain, or dehydration as sinus tachycardia, making it less specific for SVT than the very high rate listed here.

Question 9

Shock is a complication of several types of poisoning. Which measure would help reduce the risk of shock?

Accepted Answer

Answer reason: Shock involves inadequate tissue perfusion, so immediate positioning aims to support venous return and maintain central circulation while further treatment is arranged. Keeping the client supine with legs elevated increases preload and can transiently improve blood pressure and perfusion in many hypotensive states. Allowing normal activity can worsen oxygen demand and exacerbate hypotension. Elevating both head and legs does not optimize venous return and may reduce cerebral perfusion if hypotension is present.

Question 10

The pulmonary artery catheter, also known as a Swan–Ganz catheter, is commonly used to obtain specific hemodynamic measurements. What is the usual insertion site for a pulmonary artery catheter?

Accepted Answer

Answer reason: A pulmonary artery (Swan–Ganz) catheter is advanced through the venous system into the right heart and then into the pulmonary artery to measure pressures and cardiac output. Therefore, it is typically inserted via a large central vein that provides direct access to the superior vena cava/right atrium. The subclavian vein is a common central venous access site for this purpose. Arterial sites (radial or subclavian artery) are used for arterial pressure monitoring and blood sampling, not for advancing a catheter into the right heart/pulmonary artery.

Question 11

The nurse is assessing the client with an anterior-lateral MI. The nurse should add decreased cardiac output to the client’s plan of care when which finding is noted?

Accepted Answer

Answer reason: Bibasilar crackles are a classic early sign of pulmonary congestion from left-sided heart failure, signaling ineffective forward flow and hemodynamic compromise. This finding should prompt nursing actions/monitoring consistent with decreased cardiac output (vital signs, oxygenation, urine output, signs of worsening pulmonary edema). Radiating pain supports myocardial ischemia but does not by itself demonstrate impaired pump function. Normal vesicular breath sounds argue against pulmonary congestion and therefore against a low-output heart failure manifestation.

Question 12

The nurse is assessing a client with heart failure. The client is experiencing tachycardia, decreased blood pressure, and decreased peripheral pulses. The nurse interprets these symptoms as indicative of what?

Accepted Answer

Answer reason: In heart failure, pump failure can lead to hypotension and weak peripheral pulses from poor forward flow, while tachycardia develops as a compensation to maintain perfusion. This pattern most directly matches cardiogenic shock, where primary cardiac dysfunction causes systemic hypoperfusion. Distributive (including anaphylactic) shock typically presents with vasodilation and often warm, flushed skin early rather than decreased peripheral pulses from low stroke volume.

Question 13

The nurse in the cardiac unit is reviewing the conditions of the assigned clients to determine if a risk for cardiogenic shock is present. The client most at risk presents with which condition?

Accepted Answer

Answer reason: An acute MI can abruptly reduce contractility and stroke volume, leading to low cardiac output with end-organ hypoperfusion despite adequate intravascular volume. Stable CAD increases risk for MI but does not itself usually cause sudden severe pump failure. Hypotension is a manifestation of shock rather than the precipitating condition, and decreased hemoglobin is more consistent with impaired oxygen-carrying capacity (potentially contributing to other shock states) rather than direct myocardial pump failure.

Question 14

The nurse is admitting the client with a thoracic aortic aneurysm. Which intervention should the nurse plan to include?

Accepted Answer

Answer reason: Controlling blood pressure (often with beta-blockers and/or other antihypertensives) decreases shear force and helps stabilize the aneurysm. Palpation to estimate aneurysm size is inappropriate and could increase risk; aneurysm monitoring is done with imaging rather than physical manipulation. NG suction is not a standard admission intervention for this condition, and dietary teaching may be relevant for hypertension long-term but is not the most direct immediate intervention compared with medication-based BP control.

Question 15

Four clients have been admitted to the cardiac intensive care unit after experiencing acute myocardial infarctions. The nurse reviews each client’s chart to determine the assessment of cardiac damage and risk for development of cardiogenic shock. What is the percentage of damage that places the client at risk for the development of shock?

Accepted Answer

Answer reason: After an acute MI, shock risk rises substantially when roughly 40% or more of the left ventricle is infarcted because the remaining muscle cannot maintain adequate forward flow. Smaller infarct sizes (e.g., 10% or 25%) more often allow compensation via increased sympathetic tone and preload recruitment. Extremely high percentages (e.g., 90%) are not a typical clinical threshold for “risk”; they imply near-total pump failure and are less consistent with standard teaching cutoffs used for recognizing impending shock.

Question 16

Which assessment finding of a client 22 hours after a cesarean delivery requires immediate action by the nurse?

Accepted Answer

Answer reason: This finding signals decreased circulating volume and poor perfusion and requires rapid assessment and immediate intervention (notify provider/rapid response as indicated, assess bleeding and uterine tone, support IV access and fluids/blood per protocol). A low-grade temperature around 100.2°F can be expected in the first 24 hours after delivery due to dehydration/exertion. A brief vaginal “gush” can occur when pooled lochia is released on standing, and cramping is common from uterine involution; neither is as immediately life-threatening as shock physiology.

Question 17

Pulse oximetry is a noninvasive method for monitoring oxygen saturation. The pulse oximeter is considered very accurate. However, several physiologic and technical factors limit the monitoring system. Physiologic limitations in pulse oximetry include?

Accepted Answer

Answer reason: Pulse oximetry relies on detecting pulsatile arterial blood flow to estimate oxygen saturation, so adequate peripheral perfusion is necessary for a reliable signal. When perfusion is low (e.g., shock, vasoconstriction, hypothermia), the pleth waveform becomes weak and the device may read falsely low, intermittently, or not at all. This is a physiologic limitation because it stems from the patient’s circulatory status rather than equipment setup. In contrast, bright ambient light, motion, and probe misplacement are primarily technical or artifact-related limitations that can often be corrected by adjusting the environment or application.

Question 18

A 54-year-old client is admitted with an acute inferior-wall myocardial infarction (MI). During the admission interview, he says he stopped taking his metoprolol (Lopressor) 5 days ago because he was feeling better. Which nursing diagnosis takes priority for this client?

Accepted Answer

Answer reason: Abruptly stopping a beta-blocker can contribute to rebound sympathetic activity (tachycardia and increased myocardial oxygen demand), which can worsen the perfusion-demand mismatch. While pain and anxiety are important, they are addressed after ensuring circulation and minimizing ongoing myocardial ischemia because perfusion failure threatens life and cardiac function. Education/adherence problems are relevant but are not the immediate priority during an acute infarction.

Question 19

A nurse is caring for a 78-year-old female client with sick sinus syndrome who is awaiting permanent pacemaker placement. The nurse is aware that which assessment finding indicates that the client is experiencing an initial drop in cardiac output?

Accepted Answer

Answer reason: Early cerebral hypoperfusion can present as confusion, restlessness, dizziness, or other LOC changes before more obvious systemic signs fully develop. Blood pressure can remain temporarily compensated via vasoconstriction despite reduced stroke volume, so hypotension may be a later or inconsistent indicator. Diuresis would not increase with reduced output; renal perfusion typically falls, leading to decreased urine output rather than diuresis.

Question 20

A 16-year-old client involved in a motor vehicle collision arrives in the emergency department unconscious and severely hypotensive. He has several possible fractures of the pelvis and legs. Which parenteral fluid would the nurse expect to administer to this client?

Accepted Answer

Answer reason: An isotonic balanced crystalloid is a standard initial resuscitation fluid in traumatic shock and can be infused quickly in large volumes. Fresh frozen plasma and packed RBCs are blood products used when significant hemorrhage is confirmed/suspected and as part of massive transfusion protocols, but they are not typically the very first fluid hung before initial crystalloid resuscitation and blood availability/type-specific preparation. Normal saline is also isotonic, but balanced crystalloids are preferred to reduce risks such as hyperchloremic metabolic acidosis during large-volume resuscitation.

Question 21

A client had a spontaneous vaginal delivery after 18 hours of labor. Her excessive vaginal bleeding has now become a postpartum hemorrhage. Immediate nursing care of this client should include which intervention?

Accepted Answer

Answer reason: A head-down position can temporarily improve venous return and central perfusion in a severely bleeding patient as part of rapid stabilization. Hourly vital signs are too infrequent during active hemorrhage, when frequent reassessment and rapid escalation are required. Avoiding uterine massage is unsafe because uterine atony is a leading cause of postpartum hemorrhage and fundal massage is commonly used to promote uterine contraction while further treatment is obtained.

Question 22

The client with a T-1 SCI complains of lightheadedness and dizziness when the head of the bed is elevated. The client’s B/P is 84/40. Which action should the nurse implement first?

Accepted Answer

Answer reason: A high spinal cord injury can impair sympathetic tone, predisposing the patient to orthostatic hypotension when upright, leading to cerebral hypoperfusion symptoms and very low blood pressure. The immediate priority is to restore perfusion using a rapid, independent nursing action—placing the patient flat to improve venous return and cardiac output. Increasing IV fluids may help but works slower and may be inappropriate without assessing volume status, while vasopressors require a provider order and setup time. Notifying the HCP is important after stabilizing the patient, but it does not address the current hemodynamic instability first.

Question 23

The nurse is preparing the 52-year-old male client diagnosed with mitral valve regurgitation for surgery. Which statement by the client warrants immediate intervention?

Accepted Answer

Answer reason: New or worsening dyspnea with minimal exertion signals possible decompensated heart failure and impaired forward cardiac output from valvular disease, which is an immediate physiologic stability concern preoperatively. This symptom suggests pulmonary congestion and reduced functional capacity that requires prompt assessment (vitals, oxygenation, lung sounds) and escalation to the provider for optimization before surgery. In contrast, discussing advance directives and expected ICU stay reflect appropriate planning and understanding, not urgent instability. Lifelong medication education can be addressed but does not indicate an acute hemodynamic deterioration needing immediate action.

Question 24

The nurse is planning care for a 9-year-old male child with heart failure. Which nursing diagnosis should receive priority?

Accepted Answer

Answer reason: This diagnosis is an actual, present problem that directly explains the child’s heart-failure manifestations and drives immediate interventions (monitor perfusion, manage preload/afterload, support oxygenation). “Risk for decreased cardiac tissue perfusion” is a potential problem and is therefore lower priority than an existing hemodynamic compromise. Nutrition and parental anxiety are important but are addressed after stabilizing cardiac output and systemic perfusion.

Question 25

The child is diagnosed with early hypovolemic shock following surgical intervention for a ruptured appendix. Which nursing assessment findings best support early hypovolemic shock?

Accepted Answer

Answer reason: This produces tachycardia and peripheral vasoconstriction, which clinically shows as delayed capillary refill, cool extremities, and diminished peripheral pulses. Hypotension, bradycardia, mottling, and cyanosis are more consistent with later/decompensated shock rather than early compensated shock. Decreased urine output is expected in shock, so a finding that includes increased urine output does not fit the physiology.

Question 26

A 38-year-old client comes to the emergency department complaining that his heart “suddenly began to race.” After attaching him to the cardiac monitor, the nurse observes atrial tachycardia. Which rhythm strip characteristics indicate this arrhythmia?

Accepted Answer

Answer reason: A rate around 150–250/min with regular atrial and ventricular rhythms fits this pattern and the patient’s sudden-onset palpitations. Option A describes atrial flutter (sawtooth flutter waves with atrial rate exceeding ventricular rate due to AV block). Option B describes atrial fibrillation (irregularly irregular rhythm with absent discrete P waves).

Question 27

The nurse is caring for a client three hours postpartum after delivering a term newborn infant. Which assessment finding would indicate an early sign of postpartum hemorrhage?

Accepted Answer

Answer reason:  Tachycardia is an early compensatory sign of acute blood loss because sympathetic activation increases heart rate to maintain cardiac output before blood pressure falls. A jump to 125 bpm at 3 hours postpartum is therefore concerning for evolving postpartum hemorrhage even if other vital signs are not yet dramatically abnormal. A mild blood pressure decrease can occur from normal postpartum hemodynamic shifts and is typically a later/less sensitive indicator of hemorrhage than pulse changes. Soaking only one pad since delivery can be within expected lochia flow, whereas the marked tachycardia suggests possible occult or increasing bleeding.

Question 28

A client has just delivered the placenta. Which nursing action has the HIGHEST PRIORITY at this time?

Accepted Answer

Answer reason: Assessing uterine tone and lochia directly evaluates whether the uterus is contracting adequately to compress uterine blood vessels and maintain hemodynamic stability. This action enables rapid interventions (e.g., fundal massage, uterotonics, escalating care) before maternal decompensation occurs. Vital signs are important but can lag behind acute blood loss and are less sensitive early than direct uterine/bleeding assessment. Skin-to-skin and analgesia support bonding and comfort but do not supersede life-threatening hemorrhage surveillance.

Question 29

A nurse is caring for a 58-year-old male patient admitted with a suspected gastrointestinal bleed. The healthcare provider has yet to finalize a plan of care. Which of the following interventions should the nurse anticipate as a part of the initial plan of care for this patient?

Accepted Answer

Answer reason: Suspected GI bleeding is treated initially as a potential volume-loss emergency, so the priority is supporting circulation and preventing hemodynamic deterioration. Isotonic IV fluids help maintain intravascular volume while the cause and severity of bleeding are evaluated and blood products are prepared if needed. Keeping the patient NPO reduces aspiration risk and prepares for possible urgent endoscopy, anesthesia, or procedures. Giving oral fluids or starting diet/ambulation can delay stabilization and may be unsafe if the patient becomes unstable or requires immediate intervention.

Question 30

A 21 year-old male client is rushed to the emergency department after being removed from his vehicle. The client was hit by a car while riding his motorcycle. The paramedics report vitals signs prior to arrival (see exhibit). A CT scan was performed immediately upon arrival revealing a ruptured spleen and a laceration to the liver. Which early clinical manifestation by the nurse would best indicate the client is bleeding internally in the abdomen?

Accepted Answer

Answer reason: With splenic rupture and liver laceration, blood can accumulate in the peritoneal cavity before obvious external signs appear, so subtle perfusion changes are key early cues. A blood pressure of 107/54 with HR 95 can still be consistent with compensated shock and is less specific as an “early manifestation” than orthostatic symptoms. A pulsatile abdominal mass suggests an abdominal aortic aneurysm, and delirium is typically a later sign of significant hypoperfusion/hypoxia.

Question 31

A nurse is reviewing the vital signs of a post-operative patient over the past 4 hours: 12:00 PM: BP 122/76, HR 86, RR 16, Temp 99.2°F 2:00 PM: BP 116/72, HR 92, RR 18, Temp 99.6°F 4:00 PM: BP 98/64, HR 102, RR 22, Temp 100.2°F Which action should the nurse take next?

Accepted Answer

Answer reason: A progressive trend of hypotension with tachycardia and rising respiratory rate in a post-op patient suggests evolving hemodynamic instability (e.g., hemorrhage, sepsis, or third spacing) requiring prompt escalation. The BP drop to 98/64 with HR 102 indicates possible decreased circulating volume and compensatory response, which is not appropriate for routine observation alone. Treating the mild fever with an antipyretic does not address the more urgent perfusion concern and could delay recognition of deterioration. Changing the IV rate is a provider-directed intervention in many settings and should not replace timely notification when vital signs trend toward shock.

Question 32

After administration of an epidural block for labor analgesia, the client's blood pressure decreases from 130/75 to 90/50. The nurse should assist the woman to do which of the following?

Accepted Answer

Answer reason: Epidural anesthesia can cause sympathetic blockade with vasodilation and hypotension, and in late pregnancy this is often worsened by aortocaval (supine) compression that reduces venous return. Left lateral positioning displaces the uterus off the inferior vena cava, improving preload, cardiac output, and uteroplacental perfusion. Lying supine would further decrease venous return and can worsen maternal hypotension and fetal oxygenation. Semi-Fowler’s does not reliably relieve vena cava compression as effectively as a full lateral tilt/position.

Question 33

The intensive care unit nurse is caring for a client who is receiving positive-pressure ventilation and high levels of positive end-expiratory pressure (PEEP). Which hemodynamic change should the nurse expect as a result of the client’s mechanical ventilation?

Accepted Answer

Answer reason: Reduced preload leads to decreased stroke volume and therefore decreased cardiac output. High PEEP can also increase pulmonary vascular resistance and right ventricular afterload, further impairing forward flow. A frequent distractor is increased central venous pressure, which may be seen on monitoring due to transmitted intrathoracic pressure, but it does not represent improved preload and the net effect is typically reduced cardiac output.

Question 34

In which condition distal pulse preferred rather than apical pulse?

Accepted Answer

Answer reason: Distal pulses may become weak, thready, or absent earlier than central findings, making them a sensitive bedside indicator of poor perfusion. Apical pulse reflects heart rate but does not directly indicate whether blood is effectively reaching the extremities and organs. In contrast, arrhythmias are situations where the apical pulse is preferred to detect pulse deficit, not distal pulses.

Question 35

The intensive care unit nurse is caring for a client with septic shock who has a pulmonary artery catheter and whose blood pressure is being supported with continuous IV fluids and a titratable IV infusion of norepinephrine. Which finding would cause the nurse to request an order to increase the rate of continuous IV fluids?

Accepted Answer

Answer reason: A low central venous pressure suggests insufficient right-sided filling pressures, meaning the patient may still be volume depleted and could respond to increased IV fluids to improve stroke volume and perfusion. In contrast, high pulmonary artery pressure can indicate fluid overload or cardiac dysfunction and would not support increasing fluids. Low systemic vascular resistance is expected in distributive shock and primarily drives vasopressor titration rather than more fluid by itself.

Question 36

A client with chronic rheumatoid arthriti has been on prednisone for 10 years had surgery 3 days ago. the client received i.v. dexamethasone preoperatively, but postoperatively the i.v. dexamethasone order had not been continued. the nurse assesses that the client is tachycardic, hypotensive, pale, and weak. which action is the priority for the nurse to take?

Accepted Answer

Answer reason:  The priority is to support circulation when there are signs of hemodynamic instability (hypotension with compensatory tachycardia, pallor, weakness). Long-term prednisone use with perioperative steroid interruption raises concern for adrenal insufficiency/adrenal crisis, which can cause profound hypotension from inadequate cortisol-mediated vascular tone and volume responsiveness. Immediate nursing action is to treat suspected shock physiology with isotonic fluid bolus/augmentation while notifying the provider for urgent stress-dose corticosteroids. Telemetry, fall precautions, and anemia evaluation are secondary because they do not correct the life-threatening perfusion problem in the moment.

Question 37

The emergency department nurse is caring for a client admitted with septic shock. After administering prescribed intravenous fluids, which laboratory test does the nurse anticipate the physician will order to evaluate the IVF's efficacy?

Accepted Answer

Answer reason: Serial lactate is therefore a key objective marker used in sepsis bundles to assess response to IVF and ongoing resuscitation needs. Troponin evaluates myocardial injury, not global perfusion response to fluids. WBC and glucose may be abnormal in sepsis but are not reliable short-interval markers of resuscitation efficacy.

Question 38

A nurse is caring for a 65-year-old male patient who was admitted to the telemetry unit for acute decompensated heart failure. The patient is currently receiving a continuous IV infusion of furosemide. Which of the following assessments should the nurse prioritize?

Accepted Answer

Answer reason: Acute decompensated heart failure threatens oxygenation first due to pulmonary congestion and potential pulmonary edema, so airway/breathing assessments take priority. A continuous IV loop diuretic should improve fluid overload, and frequent reassessment of breath sounds, work of breathing, and oxygenation trends is the most immediate indicator of response and deterioration. Electrolyte losses (especially potassium) are important with furosemide, but they typically represent a secondary, less immediate threat than worsening respiratory status in ADHF. Peripheral perfusion checks are useful, yet they do not detect impending hypoxemic respiratory failure as early as focused respiratory assessment.

Question 39

A nurse knows that a client with moderate head injury is at risk of elevated intracranial pressure. Which of the following sign is most concerning?

Accepted Answer

Answer reason:  Rising intracranial pressure triggers a compensatory sympathetic surge to maintain cerebral perfusion, and baroreceptor response can produce reflex bradycardia as part of Cushing’s response. Marked bradycardia in a head-injured patient is therefore a red-flag sign suggesting worsening intracranial hypertension and possible impending herniation. A regular respiratory rate is reassuring rather than alarming, and isolated miosis is less specific for dangerous ICP elevation than new bradycardia in this context. Although hypotension is dangerous in head injury due to reduced cerebral perfusion, it is not the classic compensatory pattern seen with increasing ICP and is less directly indicative of an ICP-driven deterioration than bradycardia.

Question 40

A client with advanced cervical cancer is admitted with reports of uncontrolled vaginal bleeding. What is the nurse’s priority action?

Accepted Answer

Answer reason: Uncontrolled vaginal bleeding creates immediate risk for hypovolemia and hemorrhagic shock, so the first priority is to rapidly determine hemodynamic stability. Checking vital signs (especially BP, HR, RR, oxygen saturation, and level of consciousness) guides urgency, escalation, and the need for interventions like large-bore IV access, labs, and transfusion preparation. Interventions such as transfusion preparation may be necessary but should follow an initial assessment to identify instability and trends. Applying firm pressure is often not feasible/effective for internal vaginal/cervical tumor bleeding and can delay recognition of shock, while leg elevation is not definitive management and does not replace assessment.

Question 41

A 62-year-old client arrives with sudden severe abdominal pain, rigid abdomen, vomiting, and BP 86/50, HR 128, RR 28. History: peptic ulcer disease, alcohol use, black stools for 2 days. Labs: Hgb 6.9, lactate 5.8, temp 38.2°C. The client is pale, confused, and diaphoretic. What is the nurse’s priority?

Accepted Answer

Answer reason: Immediate rapid intravascular volume replacement via large-bore IV access supports perfusion while the team evaluates the likely source (GI bleed and/or perforated ulcer with peritonitis/sepsis). Blood transfusion is likely needed given the very low hemoglobin, but initial crystalloids are the fastest nursing action to improve hemodynamics and maintain organ perfusion while type-and-cross and blood product preparation occurs. Notifying the surgeon and giving a PPI address definitive management but do not correct the immediate life-threatening circulatory instability.

Question 42

Your unit has a goal of early extubation, ideally within 6 hours of CABG surgery. To achieve successful early extubation, patients must be weaned based on clinical condition, not based on time or unit routines. Which of the following criteria would exclude your patient from early extubation?

Accepted Answer

Answer reason: Escalating vasopressor/inotrope requirements indicate ongoing hemodynamic instability and inadequate physiologic reserve, making ventilator weaning and extubation unsafe. Early extubation after CABG generally requires stable blood pressure without increasing support, adequate perfusion, and the ability to tolerate the increased work of breathing after tube removal. Needing a rising epinephrine infusion suggests persistent hypotension/shock physiology and higher risk of decompensation and reintubation. In contrast, minimal chest tube output supports stability, and anxiety with purposeful interaction may indicate improving neurologic readiness rather than a contraindication. Even bradycardia with pacing available may be manageable if perfusion is adequate, but worsening hypotension requiring escalating catecholamines is a clear exclusion criterion.

Question 43

You promote hemodynamic stability in a patient with upper GI bleeding by?

Accepted Answer

Answer reason: Hemodynamic stability in upper GI bleeding depends on restoring circulating volume and oxygen-carrying capacity to prevent or treat hypovolemic shock. Rapid IV crystalloids and blood products (as indicated by ongoing bleeding, hypotension, or low hemoglobin) directly improve preload, blood pressure, and tissue perfusion. Electrolyte replacement addresses losses and dilutional shifts during resuscitation, supporting cardiac and cellular function. Monitoring vital signs/labs or CVP helps assess severity and response but does not itself stabilize the patient. Oral fluids are unsafe/ineffective in active upper GI bleeding due to aspiration risk and inability to correct significant acute volume loss quickly.

Question 44

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?

Accepted Answer

Answer reason: The combination of very low blood pressure (80/40) and a slow pulse (48) is classic for neurogenic shock and contrasts with most other shock states that are typically tachycardic. Autonomic dysreflexia more often presents with severe hypertension (often with reflex bradycardia) rather than profound hypotension. Pulmonary embolism usually causes acute dyspnea/tachypnea and often tachycardia, while hemorrhagic shock commonly features tachycardia as an early compensatory response.

Question 45

A nurse recognizes neurogenic shock is improving when?

Accepted Answer

Answer reason: Clinical improvement is best reflected by restoration of perfusion pressure as vascular tone and hemodynamic stability return, so normalization of blood pressure indicates recovery. A heart rate dropping to 40 bpm represents worsening vagal predominance rather than improvement. Cool, pale skin suggests peripheral vasoconstriction more typical of hypovolemic shock, and fever points toward infectious/inflammatory causes rather than resolution of neurogenic shock.

Question 46

A client experiencing profuse hemorrhage from placenta previa is being prepared for an emergency cesarean birth. The client exhibits signs of hypovolemia. The nurse makes it a priority to place the client in which position?

Accepted Answer

Answer reason: Placing the client in a left lateral tilt relieves vena cava compression, supporting maternal preload and improving uterine blood flow while resuscitation and surgical preparation proceed. This is the safest immediate positioning action for a hemorrhaging placenta previa patient showing hypovolemia because it optimizes hemodynamics without increasing bleeding risk. Trendelenburg is not recommended as a primary measure for shock in pregnancy and can worsen respiratory mechanics and aspiration risk, while knee-chest is used for cord prolapse rather than hemorrhage.

Question 47

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first?

Accepted Answer

Answer reason: The core priority is to treat life-threatening hypovolemic shock from burn-related capillary leak and massive fluid shifts, evidenced by profound hypotension, tachycardia, pallor, and weak/absent peripheral pulses. Immediate isotonic IV fluid resuscitation (per burn protocols such as Parkland) is the first intervention to restore circulating volume and improve tissue perfusion. Using a Doppler may help assess perfusion, but it does not correct the shock state and would delay definitive stabilization. CBC and ECG are important diagnostics/monitoring, yet they are secondary to restoring hemodynamics.

Question 48

A patient is admitted with lacerated liver as a result of blunt abdominal trauma. Which of the following nursing interventions is the priority nursing intervention for this patient?

Accepted Answer

Answer reason: In a client with a lacerated liver and suspected internal hemorrhage, the priority is to maintain circulating volume to prevent hypovolemic shock and support tissue perfusion. Administration of isotonic fluids such as normal saline is a standard first-line intervention in trauma care. Monitoring respiratory status and coagulation studies are important but secondary to stabilizing circulation, and pain management does not address the immediate life-threatening problem.

Question 49

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for?

Accepted Answer

Answer reason: Ongoing ischemia and myocardial irritability make VT/VF a high-risk, immediately life-threatening complication that requires continuous monitoring and rapid intervention. Hemodynamic patterns in cardiogenic shock typically include hypotension with narrow pulse pressure and elevated filling pressures rather than improved perfusion. Pulsus paradoxus is more characteristic of tamponade or severe asthma, and a falling CVP suggests hypovolemia rather than left-ventricular failure.

Question 50

A woman is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. Preoperatively, which of the following goals is most important for the nurse to include on the patient’s plan of care?

Accepted Answer

Answer reason: A ruptured ectopic pregnancy is an obstetric emergency where intraperitoneal hemorrhage can rapidly cause hypovolemic shock. Preoperative nursing priorities follow ABCs with immediate stabilization of circulation by supporting intravascular volume and perfusion (large-bore IV access, isotonic fluids, prepare blood as indicated). Pain control and emotional support are important but are secondary to correcting life-threatening hemodynamic compromise. Respiratory therapy is not the primary preoperative goal unless there is a separate respiratory issue; the dominant risk here is bleeding and shock.

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