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. Oliguria (low urine output) is an expected finding in hypovolemic shock due to decreased renal perfusion as blood is shunted to vital organs.
B. Hypertension is not expected; hypotension is more typical as circulating blood volume decreases.
C. Bradypnea is not common; tachypnea is expected as the body tries to compensate for decreased oxygen delivery.
D. Flushing of the skin is associated with early septic shock; in hypovolemic shock, the skin is typically cool, pale, and clammy due to peripheral vasoconstriction.

A. Epinephrine B. Dobutamine C. Methylprednisolone D. Furosemide

Correct Answer is A

Explanation

A. Epinephrine – Epinephrine is the first-line treatment for anaphylactic shock. It rapidly reverses airway constriction, hypotension, and swelling by stimulating alpha and beta-adrenergic receptors, leading to bronchodilation, vasoconstriction, and increased cardiac output.
B. Dobutamine – Dobutamine is a positive inotrope used to treat cardiogenic shock and may support cardiac output, but it does not address the airway or allergic component of anaphylaxis.
C. Methylprednisolone – This corticosteroid may be given to reduce inflammation and prevent delayed reactions, but it has a slower onset of action and is not the priority in emergency management.
D. Furosemide – This diuretic is used in fluid overload or pulmonary edema, not in the management of anaphylaxis.

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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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