Which intervention will the nurse include in the plan of care for a client who has developed cardiogenic shock?

Check temperature every 2 hours.

Auscultate and monitor breath sounds frequently.

Maintain patient in supine position.

Assess skin for flushing and itching.

Answer and Explanation

The Correct Answer is B

A. Check temperature every 2 hours – While monitoring temperature is important, it is not the priority in cardiogenic shock, which primarily affects cardiac and respiratory function.
B. Auscultate and monitor breath sounds frequently – In cardiogenic shock, pulmonary congestion and fluid overload can develop rapidly due to impaired cardiac output, so frequent assessment of lung sounds is crucial to detect crackles or signs of pulmonary edema.
C. Maintain patient in supine position – A supine position may worsen pulmonary congestion; elevating the head of the bed is typically preferred to improve ventilation and comfort.
D. Assess skin for flushing and itching – This is more relevant in allergic or anaphylactic reactions, not cardiogenic shock.

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Correct Answer is C

Explanation

A. A blood pressure of 84/50 mm Hg is more consistent with the progressive stage of shock, where compensation is failing.
B. Petechiae may be seen in disseminated intravascular coagulation (DIC), a complication of severe shock, typically not in the compensatory stage.
C. Confusion is an early sign of impaired cerebral perfusion, which can occur in the compensatory stage of shock. It reflects the body’s efforts to maintain perfusion to vital organs despite declining cardiac output.
D. Anuria (no urine output) is a late finding, typically seen in the irreversible stage of shock, indicating complete renal failure.

A. Take diuretics early in the morning and before bedtime. B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. C. Exercise at least three times per week. D. Take naproxen for generalized discomfort.

Correct Answer is C

Explanation

A. Diuretics should be taken early in the morning to avoid nocturia, but not at bedtime.
B. A weight gain of 1 kg (2.2 lb) or more in a day or 1.4–2.3 kg (3–5 lb) in a week should be reported; 0.5 kg (1 lb) in a week is not typically concerning.
C. Regular exercise (e.g., at least three times per week) is encouraged in Class I heart failure to promote cardiovascular health and endurance. This is an appropriate and recommended instruction.
D. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) and should be avoided in clients with heart failure as it may cause fluid retention and worsen heart function.

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Which intervention will the nurse include in the plan of care for a client who has developed cardiogenic shock?

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