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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. In the refractory stage, cardiac output is decreased and tissue perfusion is severely impaired, not improved.
B. Fluid balance is not restored during the refractory stage; instead, hypovolemia worsens.
C. The refractory stage is characterized by irreversible damage with worsening organ dysfunction and failure despite interventions.
D. Heart rate usually increases initially, and blood pressure typically decreases; decreased heart rate and improved blood pressure are not features of this stage.

A. Notify the health care provider immediately. B. Document the finding and continue to monitor the patient. C. Prepare the patient for temporary pacemaker insertion. D. Give atropine per agency dysrhythmia protocol.

Correct Answer is B

Explanation

A. Notifying the health care provider immediately is not necessary, as the PR interval is at the upper limit of normal (0.20 seconds) and the client is stable.
B. Document the finding and continue to monitor the patient – A PR interval of 0.20 seconds with a normal heart rate and rhythm does not require intervention; just ongoing observation.
C. Prepare the patient for temporary pacemaker insertion – This is used for serious conduction blocks or symptomatic bradycardia, which are not present here.
D. Give atropine per agency dysrhythmia protocol – Atropine is used for symptomatic bradycardia, which this client does not exhibit.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

During the refractory stage of shock in hypovolemia, which of the following responses accurately describes the physiological changes that occur?

Correct Answer is C

Explanation

A client has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines the P-R interval is 0.20 seconds. The most appropriate intervention by the nurse would be to

Correct Answer is B

Explanation

The nurse notes premature ventricular contractions (PVCs) while suctioning a client's endotracheal tube. Which action by the nurse is a priority?

A nurse assessing a client determines they are in the compensatory stage of shock. Which of the following findings support this conclusion?

A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication?

A client is scheduled for percutaneous balloon valvuloplasty to treat mitral stenosis. When explaining the advantage of valvuloplasty instead of valve replacement to the client, which information will the nurse include?

A 57-year-old-client is being admitted to the intensive care unit (ICU) with a diagnosis of possible septic shock He has a normal blood pressure, increased heart rate, decreased bowel sounds, and their skin is cold and clammy. The ICU nurse suspects the client:

A nurse is caring for a client who is has developed anaphylactic shock in response to the ingestion of strawberries. Which of the following medications should the nurse administer first?

A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?