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A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

Decreased cardiac output.

Increased pulse rate.

Postural hypotension.

Bounding pulse.

Weak thready pulse.

Hypertension.

Capillary refill greater than 3 seconds.

Capillary refill less than 3 seconds.

Pink frothy sputum.

Answer and Explanation

Correct Answer : A,B,E,G,I

Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.

Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.

Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.

Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.

Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.

Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.

Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.

Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.

Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.

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Correct Answer is A

Explanation

Choice A reason: Hypercalcemia shortens the QT interval on ECG due to accelerated cardiac repolarization. This aligns with electrolyte-related cardiac monitoring, making it the correct change the nurse would recognize as indicating possible hypercalcemia in the client’s electrocardiography assessment.

Choice B reason: Inverted T waves suggest ischemia or hypokalemia, not hypercalcemia, which shortens the QT interval. This is incorrect, as it doesn’t align with the nurse’s expected ECG change for hypercalcemia compared to the characteristic shortened QT interval.

Choice C reason: Prominent U waves are associated with hypokalemia, not hypercalcemia, which affects the QT interval. Shortened QT is correct, making this incorrect, as it’s unrelated to the nurse’s monitoring for hypercalcemia’s ECG changes in the client.

Choice D reason: Absent P waves indicate atrial fibrillation, not hypercalcemia, which shortens the QT interval. This is incorrect, as it doesn’t reflect the nurse’s anticipated ECG change for hypercalcemia, unlike the characteristic shortened QT interval in the client’s monitoring.

A. Check the level of the drainage bag. B. Reposition the client to the side. C. Place the client in good body alignment. D. Check the peritoneal dialysis system for kinks. E. Contact the primary health care provider (PHCP). F. Increase the flow rate of the peritoneal dialysis solution.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: Checking the drainage bag level ensures it’s below the abdomen to promote gravity-dependent outflow. This addresses reduced outflow in peritoneal dialysis, making it a correct action the nurse would take to resolve the inflow-outflow discrepancy safely.

Choice B reason: Repositioning to the side can dislodge catheter obstructions or improve drainage in peritoneal dialysis. This is a standard intervention for low outflow, making it a correct action the nurse would perform to correct the client’s dialysis flow issue.

Choice C reason: Good body alignment prevents catheter kinking and promotes effective drainage in peritoneal dialysis. This addresses outflow issues, making it a correct action the nurse would take to ensure proper function of the dialysis system for the client.

Choice D reason: Checking for kinks in the dialysis system identifies mechanical causes of reduced outflow. This is a key troubleshooting step, making it a correct action the nurse would perform to resolve the inflow-outflow imbalance in the client’s peritoneal dialysis.

Choice E reason: Contacting the provider is premature before troubleshooting mechanical issues like kinks or positioning. Checking the drainage bag is a priority, making this incorrect, as it delays the nurse’s initial actions to correct the dialysis outflow problem independently.

Choice F reason: Increasing the flow rate doesn’t address outflow obstruction and may worsen fluid imbalance. Repositioning is more appropriate, making this incorrect, as it’s not a safe action compared to the nurse’s focus on resolving mechanical dialysis issues first.

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A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia?

Correct Answer is A

Explanation

The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the inflow. Which actions would the nurse take? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

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A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)