Nclex Questions for Shock - Critical Care

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1. What will the nurse identi- Correct Answer: 2,3,4

fy as symptoms of hypov- Rationale 1: Fever will increase oxygen de-
olemic shock in a patient? mands but is unrelated to hypovolemic shock
Note: Credit will be given unless prolonged fever has caused severe de-
only if all correct choices hydration, reducing the circulating blood vol-
and no incorrect choices ume. Hypovolemic shock reduces tempera-
are selected. tures by peripheral shunting of blood away from
Standard Text: Select all the extremities and reducing the core metabolic
that apply. rate.
1. Temperature of 97.6°F Rationale 2: Due to decreased blood flow to
(36.4°C) the brain and peripheral areas when blood is
2. Restlessness shunted to maintain the vital organs, cerebral
3. Decrease in blood pres- hypoxia occurs, leading to a change in mental
sure of 20 mm Hg when the status.
patient sits up Rationale 3: Orthostatic hypotension is a man-
4. Capillary refill time ifestation of hypovolemic shock.
greater than 3 seconds Rationale 4: Due to decreased blood flow to
5. Sinus bradycardia of 55 the brain and peripheral areas when blood is
beats per minute shunted to maintain the vital organs, capillary
refill time will be reduced.
Rationale 5: Bradycardia is not present. The
compensatory response is to increase the
heart rate to circulate the blood faster to make
up for the fluids that are not present in hypov-
olemic shock.

2. Which laboratory finding Correct Answer: 2

should cause the nurse Rationale 1: The sodium level in hypovolemic
to suspect that a patient shock is elevated above the normal values of
is developing hypovolemic 135 to 145 mEq/L, not reduced.
shock? Rationale 2: Metabolic acidosis is present due
1. Serum sodium of 130 to an accumulation of carbonic acid, leaving a
mEq/L (130 mmol/L) bicarbonate deficit from decreased tissue per-
2. Metabolic acidosis vali- fusion.
dated by arterial blood gas- Rationale 3: Serum lactate is greater than 4
es mmol/L as a result of tissue ischemia, hypoxia,
3. Serum lactate of 3 and breakdown from decreased blood flow with
mmol/L hypovolemic shock.
4. SvO2 greater than 80% Rationale 4: SvO2 (mixed venous oxygen sat-
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uration) would be less than 60% due to de-
creased circulating blood volume or decrease
in cells to carry the oxygen. Therefore, O2 is
carried less efficiently and decreased, not in-
creased.

3. The nurse recognizes that Correct Answer: 3

which patient would be Rationale 1: Although ECG changes reflect the
most likely to develop hy- effectiveness of the heart's pumping when cir-
povolemic shock? A patient culating the blood, it is not a risk factor for
with: hypovolemic shock, which reflects a decreased
1. Decreased cardiac out- circulating volume from either blood or fluid
put losses within the intravascular system.
2. Severe constipation, Rationale 2: Severe constipation does not af-
causing watery diarrhea fect the circulating blood volume.
3. Ascites Rationale 3: Third spacing shifts move the flu-
4. Syndrome of inappropri- ids from the intravascular space into the in-
ate ADH (SIADH) terstitial space, causing a drop in the circulat-
ing blood volume. Therefore, third spacing is a
risk factor for the development of hypovolemic
shock.
Rationale 4: Overhydration does not lead to
hypovolemic shock. It leads to fluid overload,
which might cause cardiogenic shock, conges-
tive heart failure, and pulmonary edema.

4. Which finding indicates Correct Answer: 2

that a patient is experienc- Rationale 1: An increased blood supply would
ing increased peripheral re- increase color and bounding pulses as seen
sistance and vasoconstric- with vasodilation (blood engorgement) and is
tion? not present with increased peripheral resis-
1. Strong bounding pulse tance and vasoconstriction.
with deep red coloring Rationale 2: Increased peripheral resistance
2. Pale, cool extremities causes the blood supply to decrease and re-
with decreased pulses sults in decreased blood to the tissues, which
3. Increased venous en- causes pallor and decreased skin tempera-
gorgement with strong tures. The pulses would decrease in intensity
pulses with a decreased blood supply.
Rationale 3: Venous engorgement would not

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4. Faster than normal capil- result from vasoconstriction of the arteries.
lary refill time Strong pulses would not be present with vaso-
constriction from increased peripheral resis-
tance.
Rationale 4: Capillary refill times are delayed
or slowed due to decreased blood flow through
the vessels caused by the vasoconstriction
from increased peripheral resistance.

5. Which solution would be Correct Answer: 2

the most appropriate ini- Rationale 1: This is not an adequate amount of
tial volume replacement for fluid replacement.
a patient with severe GI Rationale 2: The patient requires immediate
bleeding? infusion of an adequate amount of fluid. Fluid
1. 200 mL of normal saline resuscitation begins with 500 to 1,000 mL of an
(NS) per hour for 5 hours isotonic solution.
2. A liter of Ringer's lactate Rationale 3: This is a hypotonic solution and
(RL) over 15 minutes would not help with fluid resuscitation.
3. Two liters of D5W over Rationale 4: This is a hypotonic solution and
half an hour would not help with fluid resuscitation.
4. 500 mL of 0.45% normal
saline (1/2 NS) over half an
hour

6. Which life-threatening com- Correct Answer: 2,3

plications would the nurse Rationale 1: Fluid volume overload is not an
anticipate developing in the identified complication of hypovolemic shock.
patient being treated for hy- Rationale 2: Renal insufficiency is a serious
povolemic shock? complication because of the prerenal etiology
Note: Credit will be given of hypovolemia.
only if all correct choices Rationale 3: Early identification and correction
and no incorrect choices of the fluid volume deficit in hypovolemic shock
are selected. is necessary to prevent cerebral ischemia.
Standard Text: Select all Rationale 4: Although physiologic stress can in-
that apply. crease the risk for the development of stress ul-
1. Fluid volume overload cers, it is not considered one of the common or
2. Renal insufficiency life-threatening complications of hypovolemic
3. Cerebral ischemia shock.

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4. Gastric stress ulcer Rationale 5: Pulmonary edema is not an iden-
5. Pulmonary edema tified complication of hypovolemic shock.

7. The nurse, caring for a pa- Correct Answer: 3

tient in hypovolemic shock, Rationale 1: Hypotonic solutions do not cause
will not utilize a hypotonic third spacing.
solution for fluid resuscita- Rationale 2: Hypotonic solutions do not stay in
tion because hypotonic so- the intravascular space long enough to expand
lutions: the circulating blood volume.
1. Move quickly into the Rationale 3: Hypotonic solutions do not stay in
interstitial spaces and can the intravascular space long enough to expand
cause third spacing the circulating blood volume.
2. Stay longer to expand the Rationale 4: The bore size of the needle does
intravascular space but de- not affect the displacement or shifting of fluids.
plete intracellular fluid lev-
els
3. Do not stay in the
intravascular space long
enough to expand the cir-
culating blood volume
4. Need a smaller bore nee-
dle to run at a slower rate
to keep the intravascular
space low

8. The nurse should warm in- Correct Answer: 2

travenous fluids when a Rationale 1: Hemorrhagic shock is caused by a
rapid infuser is being uti- loss of cells or blood volume and is not a result
lized to prevent which com- of infusing fluids too quickly.
plication? Rationale 2: Hypothermia can result when pro-
1. Hemorrhagic shock viding room temperature fluids at a faster pace
2. Hypothermia than the body can warm them.
3. Sepsis Rationale 3: Bacterial contamination can be
4. Cardiogenic shock avoided by sterile technique, and sepsis is not
caused by the rate or temperature of the fluid
being administered.
Rationale 4: Cardiogenic shock results from
poor ventricular functioning, not from the tem-

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perature of the intravenous fluids being admin-
istered too rapidly.

9. Which finding indicates Correct Answer: 1

that rehydration is com- Rationale 1: A CVP reading of 8 mm Hg is
plete and hypovolemic within normal range and rehydration has been
shock has been success- restored.
fully treated in a patient? Rationale 2: The mean arterial pressure (MAP)
1. CVP = 8 mm Hg should be between 60 to 70 mm Hg as evi-
2. MAP = 45 mm Hg dence of positive fluid resuscitation efforts.
3. Urinary output of 0.1 Rationale 3: Urinary output to reflect adequate
mL/kg/hr rehydration begins at 0.5 to 1 mL/kg/hr. There-
4. Hct = 54% fore, 0.1 mL is too small and renal insufficiency
may be present due to inadequate circulating
blood volume.
Rationale 4: Hematocrit (Hct) is the percent-
age of the number of RBCs per fluid volume.
The normal range is 35% to 45% for an adult.
The higher percentage represents a decreased
fluid-to-cell ratio, which implies a fluid deficit
and rehydration is not complete. An Hct of
54% is critical and increases the risk of clots,
strokes, and other vessel obstruction from po-
tential hemolysis and sluggishness of cellular
movements.

10. A patient is demonstrat- Correct Answer: 2

ing pulmonary edema, hy- Rationale 1: Pulmonary edema would not be
potension, and delayed present in hypovolemic shock.
capillary refill. The nurse Rationale 2: In cardiogenic shock, there is a low
suspects the patient is ex- cardiac output, hypotension, and pulmonary
periencing which type of edema.
shock? Rationale 3: Pulmonary edema would not be
1. Hypovolemic present in anaphylactic shock.
2. Cardiogenic Rationale 4: Pulmonary edema would not be
3. Anaphylactic present in obstructive shock
4. Obstructive

11.

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A patient, experiencing va- Correct Answer: 1,2,3
sodilation, is diagnosed Rationale 1: One etiology of distributive shock
with distributive shock. The is sepsis.
nurse will assess the pa- Rationale 2: One etiology of distributive shock
tient for which etiologies? is spinal cord injury.
Note: Credit will be given Rationale 3: One etiology of distributive shock
only if all correct choices is anaphylaxis.
and no incorrect choices Rationale 4: Hemorrhage is not an etiology of
are selected. distributive shock.
Standard Text: Select all Rationale 5: Pulmonary embolism is not an
that apply. etiology of distributive shock.
1. Sepsis
2. Spinal cord injury
3. Anaphylaxis
4. Hemorrhage
5. Pulmonary embolism

12. The nurse is concerned that Correct Answer: 1,2

a patient is at risk for de- Rationale 1: Advanced age increases the risk
veloping obstructive shock for development of pulmonary emboli, which is
because of which assess- one cause of obstructive shock.
ment findings? Rationale 2: Atrial fibrillation increases the risk
Note: Credit will be given for developing pulmonary emboli, which is one
only if all correct choices cause of obstructive shock.
and no incorrect choices Rationale 3: Bacteremia increases a patient's
are selected. risk of developing septic shock and not obstruc-
Standard Text: Select all tive shock.
that apply. Rationale 4: A spinal cord injury increases the
1. Age 80 risk for developing distributive shock and not
2. History of atrial fibrilla- obstructive shock.
tion Rationale 5: A latex allergy increases the risk
3. Bacteremia for developing distributive shock and not ob-
4. T3 spinal cord injury structive shock.
5. Latex allergy

13. A patient is experiencing Correct Answer: 1

an anaphylactic reaction to Rationale 1: In an anaphylactic reaction leading
a medication. The nurse to distributive shock, the release of histamine
is concerned that the pa- causes vasodilation with plasma leakage. Va-

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tient will develop distribu- sodilation leads to profound hypotension, hy-
tive shock because: povolemia from fluid extravasation, reduced re-
1. The release of histamine load, and reduced cardiac output.
causes vasodilation with Rationale 2: Sympathetic innervation is not in-
plasma leakage. terrupted in an anaphylactic reaction.
2. Sympathetic innervation Rationale 3: Microorganisms do not overwhelm
is interrupted. the vascular system in an anaphylactic reac-
3. Microorganisms over- tion.
whelm the vascular system. Rationale 4: Parasympathetic innervation func-
4. Parasympathetic inner- tioning unopposed is not a characteristic of an
vation functions are unop- anaphylactic reaction.
posed.

14. A patient is diagnosed with Correct Answer: 1

cardiac tamponade. When Rationale 1: Cardiac tamponade can lead to
planning care, the nurse obstructive shock.
will include interventions Rationale 2: Cardiac tamponade will not lead to
to address which type of hypovolemic shock.
shock? Rationale 3: Cardiac tamponade will not lead to
1. Obstructive distributive shock.
2. Hypovolemic Rationale 4: Cardiac tamponade will not lead to
3. Distributive cardiogenic shock.
4. Cardiogenic

15. The nurse, caring for a pa- Correct Answer: 1

tient recovering from an Rationale 1: One etiology of cardiogenic shock
acute myocardial infarc- is a myocardial infarction.
tion, is planning interven- Rationale 2: Acute myocardial infarction does
tions to reduce the risk of not cause hypovolemic shock.
which type of shock? Rationale 3: Acute myocardial infarction does
1. Cardiogenic not cause distributive shock.
2. Hypovolemic Rationale 4: Acute myocardial infarction does
3. Distributive not cause obstructive shock.
4. Obstructive

16. A patient with cardiomy- Correct Answer: 1

opathy is demonstrating Rationale 1: In cardiogenic shock, cardiac out-
signs of cardiogenic shock. put is reduced, leading to poor tissue perfu-
The nurse realizes that this sion.

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type of shock is due to: Rationale 2: In cardiogenic shock, stroke vol-
1. Reduced cardiac output ume is decreased.
2. Increased stroke volume Rationale 3: There is not a reduction of blood
3. Reduced blood volume volume in cardiogenic shock.
4. Blood flow blocked in the Rationale 4: There is not a blockage of blood
pulmonary circulation flow through the pulmonary circulation in car-
diogenic shock.

17. The nurse is explaining the Correct Answer: 1,2,3,4,5,6

mechanism of a pulmonary Rationale 1: The obstruction caused by the
embolism to the family of a pulmonary embolism increases the afterload
patient diagnosed with the of the right ventricle, causing right ventricular
disorder. Place in order the failure.
steps the nurse will use Rationale 2: The embolus prevents adequate
to instruct the family about blood flow from the pulmonary circulation to the
this disease process. left ventricle.
Standard Text: Click and Rationale 3: Because blood flow from the pul-
drag the options below to monary circulation is blocked, left ventricular
move them up or down. preload drops.
Choice 1. Blood clot causes Rationale 4: Because left ventricular preload is
backup of blood in the right decreased, there is not enough blood in the
ventricle. heart to pump, causing decreased cardiac out-
Choice 2. Blood clot blocks put.
blood to the left ventricle. Rationale 5: A lack of blood circulating will lead
Choice 3. Left ventricle to hypotension.
does not get enough blood Rationale 6: When the blood is backed up and
to pump through the body. is not being pumped into the general circula-
Choice 4. Amount of blood tion, tissue perfusion is reduced.
the heart has to pump to the
body drops.
Choice 5. Blood pressure
drops.
Choice 6. Amount of blood
going to the body drops.

18. A patient is being treated Correct Answer: 1

for pericarditis. The nurse Rationale 1: Acute pericarditis and the devel-
will plan interventions to opment of fluid accumulation in the pericardial
prevent the onset of which space can lead to the development of obstruc-

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type of shock? tive shock.
1. Obstructive Rationale 2: Pericarditis is not a risk factor for
2. Hypovolemic the development of hypovolemic shock.
3. Distributive Rationale 3: Pericarditis is not a risk factor for
4. Cardiogenic the development of distributive shock.
Rationale 4: Pericarditis is not a risk factor for
the development of cardiogenic shock.

19. A patient is brought to Correct Answer: 1,2,3,4

the emergency department Rationale 1: Venoms such as bee stings can
with manifestations of ana- trigger anaphylactic shock.
phylactic shock. What will Rationale 2: Drugs can trigger anaphylactic
the nurse assess as pos- shock.
sible causes for this disor- Rationale 3: Latex can trigger anaphylactic
der? shock.
Note: Credit will be given Rationale 4: Contrast media for diagnostic tests
only if all correct choices can trigger anaphylactic shock.
and no incorrect choices Rationale 5: Myocardial infarction is not a trig-
are selected. ger for anaphylactic shock.
Standard Text: Select all
that apply.
1. Recent bee sting
2. Ingestion of drugs
3. History of latex allergy
4. Recent diagnostic imag-
ing tests
5. Recent myocardial infarc-
tion

20. During an assessment the Correct Answer: 1,2,3

nurse is concerned that a Rationale 1: Hypotension is a manifestation of
patient is developing car- cardiogenic shock.
diogenic shock. What did Rationale 2: Delayed capillary refill is a mani-
the nurse assess in this pa- festation of cardiogenic shock.
tient? Rationale 3: Crackles are a manifestation of
Note: Credit will be given cardiogenic shock.
only if all correct choices Rationale 4: Bradycardia is not a manifestation
and no incorrect choices of cardiogenic shock.
are selected.

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Standard Text: Select all Rationale 5: Warm dry skin is not a manifesta-
that apply. tion of cardiogenic shock.
1. Systolic blood pressure
82 mm Hg
2. Capillary refill 10 sec-
onds
3. Crackles bilateral lung
bases
4. Heart rate 55 and regular
5. Warm dry skin

21. A patient is brought to Correct Answer: 1

the emergency department Rationale 1: Jugular vein distention is a mani-
with hypotension, tachycar- festation of cardiogenic shock.
dia, reduced capillary refill, Rationale 2: The mucous membranes are not
and oliguria. During the as- dry in cardiogenic shock.
sessment, the nurse deter- Rationale 3: The skin turgor is not poor in car-
mines the patient is expe- diogenic shock.
riencing cardiogenic shock Rationale 4: Thirst is not a manifestation of
because of which addition- cardiogenic shock.
al finding?
1. Jugular vein distention
2. Dry mucous membranes
3. Poor skin turgor
4. Thirst

22. A patient being treated for Correct Answer: 1,2,3

cardiogenic shock is be- Rationale 1: This finding is consistent with pul-
ing hemodynamically mon- monary vascular congestion.
itored. Which findings are Rationale 2: This finding is consistent with fluid
consistent with the pa- volume overload.
tient's diagnosis? Rationale 3: This finding is consistent with pul-
Note: Credit will be given monary vascular congestion.
only if all correct choices Rationale 4: This finding is not consistent with
and no incorrect choices cardiogenic shock.
are selected. Rationale 5: This finding is not consistent with
Standard Text: Select all cardiogenic shock.
that apply.
1. Elevated pulmonary arte-

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rial wedge pressure
2. Elevated central venous
pressure
3. Elevated systemic vascu-
lar resistance index
4. Elevated mean arterial
pressure
5. Elevated stroke volume

23. The nurse is caring for Correct Answer: 1,2,3

a patient recovering from Rationale 1: Hypotension is a manifestation of
a spinal cord injury sus- neurogenic shock because of the loss of auto-
tained during a motor vehi- nomic reflexes.
cle crash. What assessment Rationale 2: Bradycardia occurs because of the
findings indicate that the loss of sympathetic innervation.
patient is developing neu- Rationale 3: Warm dry skin occurs because of
rogenic shock? a loss of cutaneous control of sweat glands.
Note: Credit will be given Rationale 4: Abdominal cramping is not a man-
only if all correct choices ifestation of neurogenic shock.
and no incorrect choices Rationale 5: Palpitations are not seen in neuro-
are selected. genic shock.
Standard Text: Select all
that apply.
1. Hypotension
2. Bradycardia
3. Warm dry skin
4. Abdominal cramps
5. Palpitations

24. A patient is demonstrating Correct Answer: 1

signs of obstructive shock Rationale 1: Chest pain is a symptom associat-
but the cause has yet to ed with a massive pulmonary embolus.
be determined. Which find- Rationale 2: Hypotension is seen in other caus-
ing indicates the patient is es of obstructive shock and is not a symptom
experiencing a pulmonary that differentiates the cause as being from a
embolism as the cause for pulmonary embolus.
obstructive shock? Rationale 3: Tachycardia is seen in other caus-
1. Chest pain es of obstructive shock and is not a symptom
2. Hypotension that differentiates the cause as being from a

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3. Tachycardia pulmonary embolus.
4. Oliguria Rationale 4: Oliguria is seen in other causes
of obstructive shock and is not a symptom that
differentiates the cause as being from a pul-
monary embolus.

25. The nurse is preparing Correct Answer: 1,2,3,5

medications for a patient Rationale 1: Dopamine is commonly used in
being treated for cardio- the treatment of cardiogenic shock.
genic shock. Which med- Rationale 2: Norepinephrine is commonly used
ications will the nurse most in the treatment of cardiogenic shock.
likely provide to this pa- Rationale 3: Dobutamine may be used in the
tient? patient with cardiogenic shock who has an ad-
Note: Credit will be given equate blood pressure.
only if all correct choices Rationale 4: Epinephrine is not used in the
and no incorrect choices treatment of cardiogenic shock.
are selected. Rationale 5: Phenylephrine is a vasopressor
Standard Text: Select all and may be used in the patient with cardiogenic
that apply. shock who is receiving dobutamine.
1. Dopamine
2. Norepinephrine
3. Dobutamine
4. Epinephrine
5. Phenylephrine

26. A patient with neurogenic Correct Answer: 4

shock is demonstrating Rationale 1: Limiting movement will not cor-
bradycardia. What action rect bradycardia in the patient with neurogenic
will the nurse take at this shock.
time? Rationale 2: Crystalloids are used to correct
1. Limit patient movement. vasodilation.
2. Prepare to administer Rationale 3: Phenylephrine is used in the pa-
crystalloids. tient with neurogenic shock to correct hypoten-
3. Administer phenyle- sion.
phrine as prescribed. Rationale 4: Bradycardia in neurogenic shock
4. Administer atropine as is corrected by the administration of atropine at
prescribed. the dose of 0.5 to 1.0 mg intravenous every 5
minutes to a total dose of 3 mg.

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27. A patient is experiencing Correct Answer: 1,2,3
acute respiratory distress Rationale 1: Epinephrine produces bronchodi-
after eating an item of a lation, improving the respiratory status. The
known food allergy. What route of administration is initially intramuscular.
interventions will the nurse Rationale 2: Supplemental oxygen is used in
implement when providing the treatment of anaphylactic shock.
emergency care to this pa- Rationale 3: Hydrogen ion blockers such as
tient? diphenhydramine may be administered to block
Note: Credit will be given the histamine effects.
only if all correct choices Rationale 4: Vasopressin is not used in the
and no incorrect choices treatment of anaphylactic shock.
are selected. Rationale 5: Antithrombolytic agents are not
Standard Text: Select all used in the treatment of anaphylactic shock.
that apply.
1. Administer epinephrine
1:1000 intramuscularly.
2. Apply oxygen via face
mask as prescribed.
3. Provide diphenhy-
dramine 25 mg intra-
venous.
4. Administer vasopressin.
5. Prepare to administer
antithrombolytic agents as
prescribed.

28. A patient is receiving Correct Answer: 1

phenylephrine 50 mcg/min Rationale 1: The expected effect of this med-
as treatment for shock. ication is an increase in blood pressure.
Which assessment finding Rationale 2: Phenylephrine does not increase
indicates this medication is the heart rate.
effective? Rationale 3: Phenylephrine does not affect the
1. Blood pressure 110/68 respiratory rate.
mm Hg Rationale 4: Decreased peripheral pulses is a
2. Heart rate 110 side/toxic effect of this medication.
3. Respiratory rate 12 and
regular
4. Decreased peripheral
pulses
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29. A patient weighing 220 Correct Answer: 60

lbs is prescribed 10 Rationale : Determine the patient's weight in
mcg/kg/min of dopamine kg by dividing 220 lbs by 2.2 or 100 kg. Then
to improve cardiac output multiply the number of mcg of medication the
from cardiogenic shock. patient is to receive per minute by 100 kg or
How many milligrams of 10 mcg × 100 kg = 1,000 mcg. This is the
dopamine will the patient dosage the patient will receive in 1 minute.
receive in an hour? To determine the amount of medication in 1
hour, multiply 1,000 mcg × 60 = 60,000 mcg.
Using the conversion 1 mg = 1,000 mcg, divide
60,000 mcg by 1,000 mcg to determine that
the patient will receive 60 mg of dopamine in
1 hour.

30. Which assessment finding Correct Answer: 1

indicates that an infusion of Rationale 1: An expected action for epinephrine
intravenous epinephrine 4 is bronchodilation as evidenced by less wheez-
mcg/min is effective in the ing.
treatment of a patient with Rationale 2: Epinephrine increases heart rate.
anaphylactic shock? Rationale 3: Epinephrine increases blood pres-
1. Reduced wheezing sure.
2. Heart rate 55 and regular Rationale 4: Epinephrine lowers the respiratory
3. Blood pressure 98/50 mm rate. This respiratory rate indicates that epi-
Hg nephrine has not been effective.
4. Respiratory rate 28

31. A patient is receiving nor- Correct Answer: 1,2,3

epinephrine 30 mcg/min Rationale 1: At high doses of norepinephrine,
for treatment of refractory decreased peripheral pulses indicates signifi-
shock. Which assessment cant vasoconstriction.
findings suggest the pa- Rationale 2: At high doses of norepinephrine, a
tient is experiencing pe- drop in body temperature indicates significant
ripheral vasoconstriction vasoconstriction.
from the medication? Rationale 3: At high doses of norepinephrine,
Note: Credit will be given paresthesias indicate significant vasoconstric-
only if all correct choices tion.
and no incorrect choices Rationale 4: This medication does not cause a
are selected. drop in blood pressure.
Standard Text: Select all Rationale 5: An increase in cardiac output is an
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that apply. expected effect of this medication and does not
1. Decreased peripheral indicate significant vasoconstriction.
pulses
2. Drop in body temperature
3. Onset of paresthesias
4. Drop in blood pressure
5. Increased cardiac output

32. A patient is pre- Correct Answer: 1

scribed vasopressin 0.03 Rationale 1: The dose of 0.03 units/min is usu-
units/minute as treatment ally added to a norepinephrine infusion.
for septic shock. What ac- Rationale 2: This medication should always be
tion will the nurse take administered via an infusion pump.
when providing this med- Rationale 3: A rapid infuser is used to deliver
ication? large amounts of warmed crystalloid or blood
1. Provide the vasopressin to a patient over a short period of time. It is not
infusion in addition to a used for medication administration.
norepinephrine infusion. Rationale 4: This medication does not need to
2. Infuse through a periph- be administered with 0.9% normal saline.
eral line.
3. Utilize a rapid infuser.
4. Administer with 0.9%
normal saline.

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