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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: Malodorous flatus 2 days post-colostomy is normal, indicating bowel function resumption. This aligns with postoperative colostomy expectations, making it the correct interpretation by the nurse, as flatus is an expected milestone in the client’s recovery process.

Choice B reason: Ischemic bowel causes pain, fever, or absent output, not just malodorous flatus, which is normal post-colostomy. This is incorrect, as it misinterprets a typical finding as a serious complication in the nurse’s assessment of the client’s stoma.

Choice C reason: Flatus doesn’t indicate the need for a nasogastric tube, which is used for obstruction or ileus. Normal flatus is expected, making this incorrect, as it wrongly suggests intervention for a typical post-colostomy finding in the nurse’s evaluation.

Choice D reason: Malodorous flatus is unrelated to preoperative bowel preparation; it’s a normal post-colostomy event. This is incorrect, as it misattributes a standard recovery sign to surgical preparation, unlike the nurse’s correct interpretation of expected bowel function.

A. Failure to analyze the level of care needed by the patient. B. Failure to respect the patient’s wishes. C. Wrongful death. D. Failure to take appropriate action.

Correct Answer is D

Explanation

Choice A reason: Analyzing care levels is important, but the nurse’s negligence lies in not addressing the critical magnesium level. Reporting to the practitioner is the appropriate action, making this incorrect, as it’s less specific than the failure to act on a critical lab result.

Choice B reason: Respecting patient wishes relates to DNR but doesn’t negate the need to report critical labs for non-resuscitative care. Failure to act is the issue, making this incorrect, as it misapplies the DNR to the nurse’s duty to address the magnesium level.

Choice C reason: Wrongful death assumes patient harm or death, which isn’t indicated here. Failure to act on the critical magnesium level is the negligence, making this incorrect, as it overstates the outcome compared to the nurse’s inaction on the lab result.

Choice D reason: Failure to take appropriate action, such as reporting a critical magnesium level of 1.1 mEq/L, is negligent, regardless of DNR status. This aligns with nursing standards, making it the correct action the nurse neglected, as critical labs require practitioner notification.

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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

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

Correct Answer is A

Explanation

The laboratory notifies the night nurse that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not inform the practitioner because of the patient’s code status. In doing so, the nurse is negligent for which action?

Correct Answer is D

Explanation

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