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. Serum sodium levels are important to monitor over time with diuretic therapy but do not provide immediate feedback on the effect of a bolus dose of furosemide.
B. Daily weight helps assess long-term fluid status but is not helpful for evaluating an acute response.
C. Hourly urine output is the most appropriate and immediate measure to assess the effectiveness of a bolus dose of IV furosemide, especially in a critically ill client with acute pulmonary edema.
D. 24-hour intake and output provides a broader picture but does not offer real-time assessment like hourly output does.

A. Prosthetic cardiac valves B. Sedentary lifestyle C. Radiation exposure D. Cardiac catheterization

Correct Answer is A

Explanation

A. The presence of prosthetic heart valves is a significant risk factor for infective endocarditis due to the increased likelihood of bacterial colonization.
B. Sedentary lifestyle is not a direct risk factor for infective endocarditis, though it may contribute to other cardiovascular issues.
C. Radiation exposure – While it may affect cardiac tissue, it is not considered a risk factor for infective endocarditis.
D. Cardiac catheterization – While it is an invasive procedure, it is not a major or common risk factor for infective endocarditis compared to prosthetic valves or structural heart defects.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse discussing potential risk factors of infective endocarditis with a hospitalized client would include which of the following as a potential risk factor of this disease process?

Correct Answer is A

Explanation

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