The nurse overseeing care in the intensive care unit (ICU) reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock?

The client admitted with malignant hypertension

The client admitted following a stroke

The client admitted with acute kidney injury

The client admitted following a myocardial infarction (MI)

Answer and Explanation

The Correct Answer is D

A. Malignant hypertension poses risks for other conditions but is not the primary risk factor for cardiogenic shock.
B. A stroke does not directly lead to cardiogenic shock, though it may have other significant complications.
C. Acute kidney injury affects renal function but is not the primary risk for cardiogenic shock.
D. A myocardial infarction (MI) can impair the heart's pumping ability, leading to cardiogenic shock. This is due to the damage to heart muscle that can severely impact cardiac output and blood pressure.

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Correct Answer is C

Explanation

A. The treatment for vancomycin-resistant enterococcus (VRE) in a previous admission is not directly related to the development of CLABSI in the current situation. The infection is more likely caused by improper handling or maintenance of the central line.
B. Drawing blood cultures from the central line, while not ideal, is not the most likely cause of CLABSI. Proper technique can mitigate the risk of introducing infection during this procedure.
C. Changing the central line dressing using clean technique instead of sterile technique increases the risk of introducing pathogens to the central line site, leading to a central line-associated bloodstream infection (CLABSI).
D. Receiving antibiotics and intravenous fluids through the same line does not typically cause CLABSI if the line is properly maintained and sterile techniques are observed during administration.

A. Encouraging the client to use a cane as needed for mobility B. Encouraging the client to use their right hand for daily activities C. Encouraging the client to consume a soft diet and thickened liquids D. Encouraging the client to complete all activities of daily living (ADLs) independently

Correct Answer is A

Explanation

A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.

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The nurse overseeing care in the intensive care unit (ICU) reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client in the intensive care unit (ICU) with a central venous catheter has developed signs and symptoms that are suggestive of a central line-associated bloodstream infection (CLABSI). What is most likely the cause of the infection?

Correct Answer is C

Explanation

A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

Correct Answer is A

Explanation

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