NCLEX Physiological Adaptation (Medical Emergencies and Shock)

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?

Accepted Answer

Start a vasopressor such as norepinephrine

Answer

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?

Accepted Answer

Restlessness and tachycardia

Answer

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?

Accepted Answer

Prepare for immediate needle decompression or chest tube insertion

Answer

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?

Accepted Answer

Sit the client upright and check for bladder distention or other triggers

Answer

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?

Accepted Answer

Epinephrine intramuscularly

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Physiological Adaptation (Medical Emergencies and Shock)