NCLEX Physiological Adaptation (Medical Emergencies and Shock) — Questions and Answers
Question 1: A client with sepsis has a blood pressure of 82/48 mm Hg, heart rate of 124/min, and a lactate of 4.8 mmol/L after a 30 mL/kg crystalloid bolus. Which action does the nurse anticipate next?
- Start a vasopressor such as norepinephrine (Correct answer)
- Give an additional diuretic dose
- Restrict all IV fluids
- Administer a beta blocker to control heart rate
Correct answer: Start a vasopressor such as norepinephrine
Persistent hypotension after adequate fluid resuscitation in septic shock calls for vasopressors, usually norepinephrine, to keep mean arterial pressure at or above 65 mm Hg. Diuretics and beta blockers would worsen perfusion, and the tachycardia is compensatory.
Question 2: Which finding in a client with suspected hypovolemic shock is the earliest sign of compensation?
- Marked hypotension
- Anuria
- Restlessness and tachycardia (Correct answer)
- Loss of consciousness
Correct answer: Restlessness and tachycardia
In early compensated shock, sympathetic stimulation raises heart rate and causes anxiety or restlessness while blood pressure may still be normal. Hypotension, anuria, and loss of consciousness are late findings of decompensated or irreversible shock.
Question 3: A client with a suspected tension pneumothorax has absent breath sounds on the left, tracheal deviation to the right, and severe hypotension. What is the priority nursing action?
- Obtain a chest x-ray before any intervention
- Prepare for immediate needle decompression or chest tube insertion (Correct answer)
- Administer an oral analgesic
- Place the client in a supine position with legs flat
Correct answer: Prepare for immediate needle decompression or chest tube insertion
Tension pneumothorax is a life-threatening emergency that compromises venous return and cardiac output. It is diagnosed clinically, and immediate decompression with a needle then chest tube is required without waiting for imaging.
Question 4: A client with a spinal cord injury at T4 develops a severe pounding headache, flushing above the injury, and a blood pressure of 210/110 mm Hg. What is the nurse's first action?
- Place the client flat and give a sedative
- Sit the client upright and check for bladder distention or other triggers (Correct answer)
- Administer an oral laxative
- Apply a heating pad to the lower extremities
Correct answer: Sit the client upright and check for bladder distention or other triggers
These are signs of autonomic dysreflexia, a medical emergency. Raise the head of the bed or sit the client up to lower blood pressure, then find and remove the trigger, most often a distended bladder or fecal impaction, before giving an antihypertensive if needed.
Question 5: A client is brought to the emergency department with suspected anaphylaxis after a bee sting. Which medication does the nurse expect to administer first?
- Diphenhydramine IV
- Epinephrine intramuscularly (Correct answer)
- Methylprednisolone IV
- Albuterol nebulizer
Correct answer: Epinephrine intramuscularly
Intramuscular epinephrine (0.3 to 0.5 mg of 1 mg/mL in the anterolateral thigh for adults) is the first-line treatment for anaphylaxis. Antihistamines, corticosteroids, and bronchodilators are adjuncts and do not reverse airway edema or shock.
Question 6: A nurse is monitoring a client with increased intracranial pressure. Which finding indicates a late and ominous sign?
- Mild headache
- Cushing's triad of hypertension with widened pulse pressure, bradycardia, and irregular respirations (Correct answer)
- Nausea
- Slight restlessness
Correct answer: Cushing's triad of hypertension with widened pulse pressure, bradycardia, and irregular respirations
Cushing's triad (rising systolic pressure with widened pulse pressure, bradycardia, and irregular respirations) signals impending brainstem herniation. Early signs include a change in level of consciousness, headache, and restlessness.
