Page 2570 - Saunders Comprehensive Review For NCLEX-RN

Think about the stages of shock. Noting the signs of restlessness, agitation and
confusion, as well as the low blood pressure and decreased urinary output, will
direct you to Stage 2 as the correct answer.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Complex Care: Shock
Health Problem: Adult Health: Cardiovascular: Shock
Priority Concepts: Clinical Judgment; Perfusion
Reference: Lewis et al. (2017), pp. 1594-1595.

869. Answer: 1

Rationale: The client in this question is likely experiencing cardiogenic shock
secondary to heart failure exacerbation. It is important to note that if the shock state
is cardiogenic in nature, the infusion of volume-expanding fluids may result in
pulmonary edema; therefore, restoration of cardiac function is the priority for this
type of shock. Cardiotonic medications such as digoxin, dopamine, or
norepinephrine may be administered to increase cardiac contractility and induce
vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are
volume-expanding fluids and may further complicate the client’s clinical status;
therefore, they should be avoided.
Test-Taking Strategy: Note the strategic word, priority, and focus on the subject,
suspected shock in a client hospitalized for heart failure exacerbation. Recalling that
this client is at risk for fluid volume overload will direct you to the correct option.
Also, note that options 2, 3, and 4 are comparable or alike and involve the
administration of intravenous solutions.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Complex Care: Shock
Health Problem: Adult Health: Cardiovascular: Shock
Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman, Rebar (2018), p. 700.

870. Answer: 3, 4, 5

Rationale: Sepsis diagnostic criteria with regard to signs and symptoms include
the following: Fever (temperature higher than 100.9° F [38.3° C]) or hypothermia
(core temperature lower than 97° F [36° C]), tachycardia (heart rate above 90 beats
per minute), tachypnea (respiratory rate above 22 breaths per minute), systolic blood
pressure (SBP) less than or equal to 100 mm Hg or arterial hypotension (SBP below
90 mm Hg), MAP less than 70 mm Hg, or a decrease in SBP of more than 40 mm Hg,
altered mental status, edema or positive fluid balance, oliguria, ileus (absent bowel
sounds), and decreased capillary refill or mottling of skin.
Test-Taking Strategy: Note the subject, clinical findings consistent with sepsis
diagnostic criteria. Recalling that a minimum of 30 mL/hr of urine is adequate will

2570