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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 B

Explanation

Choice A reason: Administering furosemide without a provider’s order is outside nursing scope and risks harm. Decreasing IV fluids addresses elevated CVP, making this incorrect, as it bypasses protocol compared to the nurse’s priority of adjusting fluids and consulting the provider.

Choice B reason: A CVP of 16 cm H2O suggests fluid overload; decreasing IV fluids and notifying the provider prevents worsening heart failure. This aligns with hemodynamic monitoring protocols, making it the correct action for the nurse to take to address the client’s elevated CVP.

Choice C reason: Documenting the CVP is necessary but doesn’t address the urgent fluid overload indicated by 16 cm H2O. Decreasing fluids is proactive, making this incorrect, as it delays intervention compared to the nurse’s priority of managing the client’s high CVP.

Choice D reason: Checking urine specific gravity assesses hydration but is less urgent than addressing elevated CVP with fluid adjustment. Notifying the provider takes precedence, making this incorrect, as it’s secondary to the nurse’s action to manage fluid overload immediately.

A. Assessing blood pressure. B. Measuring intake and output. C. Elevating the head of the bed. D. Checking for presence of dependent edema.

Correct Answer is C

Explanation

Choice A reason: Assessing blood pressure monitors fluid overload but doesn’t immediately reduce respiratory strain. Elevating the head of the bed improves breathing, making this incorrect, as it’s less urgent than the nurse’s first action to prevent harm from fluid overload.

Choice B reason: Measuring intake and output tracks fluid balance but is less immediate than elevating the bed to ease breathing. This is incorrect, as it delays the nurse’s priority action to alleviate respiratory distress in a client with suspected fluid overload.

Choice C reason: Elevating the head of the bed is the first action to reduce respiratory distress in fluid overload by decreasing venous return. This aligns with acute care priorities, making it the correct action to prevent harm in the client with suspected hypervolemia.

Choice D reason: Checking for dependent edema confirms fluid overload but doesn’t address immediate respiratory risks. Elevating the bed is urgent, making this incorrect, as it’s secondary to the nurse’s first action to improve breathing in the fluid-overloaded client.

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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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Explanation

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