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 A

Explanation

A. Heart failure often presents with dyspnea, crackles (from pulmonary congestion), jugular vein distention, dependent edema, and hepatomegaly due to fluid overload and impaired cardiac output—these are classic signs.
B. Pulmonary embolism typically causes sudden dyspnea, chest pain, and tachypnea but not hepatomegaly or dependent edema.
C. Tension pneumothorax presents with tracheal deviation, absent breath sounds on one side, and hypotension—different from the systemic fluid overload signs described.
D. Cardiac tamponade presents with muffled heart sounds, hypotension, and jugular vein distention (Beck's triad), but it does not cause crackles, hepatomegaly, or peripheral edema.

A. Friction rub B. Wheezes C. Rales D. Rhonchi

Correct Answer is A

Explanation

A. A friction rub is the characteristic auscultatory finding in pericarditis. It is a high-pitched, scratchy sound heard best at the left lower sternal border and is caused by the inflamed pericardial layers rubbing against each other.
B. Wheezes are continuous, musical sounds usually associated with airway narrowing, such as in asthma or COPD.
C. Rales (crackles) are heard in conditions like pulmonary edema or pneumonia, not pericarditis.
D. Rhonchi are low-pitched, snoring sounds associated with mucus or obstruction in the larger airways.

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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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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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