select the stage of shock that is accurately paired with its characteristic

HESI LPN

Leadership and Management HESI Test Bank

1. Select the stage of shock that is accurately paired with its characteristic.

A. The initial stage of shock: Hyperventilation occurs and the blood pH rises.
B. The compensatory stage of shock: Hypoxia occurs and lactic acid rises.
C. The progressive stage of shock: Histamine is released; fluid and proteins leak into surrounding tissues and the blood thickens.
D. The refractory stage of shock: Potassium ions leak out; sodium ions build up, and metabolic acidosis increases.

Correct answer: C

Rationale: The progressive stage of shock is accurately described as the stage where histamine is released, leading to fluid and proteins leaking into surrounding tissues and the blood thickening. In this stage, the body's compensatory mechanisms are overwhelmed, resulting in a cascade of events that worsen the shock state. Choice A is incorrect as hyperventilation and a rise in blood pH are more characteristic of the compensatory stage. Choice B is incorrect as hypoxia and a rise in lactic acid are more typical of the progressive stage. Choice D is incorrect as the described electrolyte imbalances and metabolic acidosis are more aligned with the refractory stage of shock.

2. What does the mnemonic device ABCDE stand for?

A. Allergy, bleeding, chemicals, dietary, environment
B. Allergy, bleeding, cardio, diabetes, endocrine
C. Allergy, bleeding, cardio, digestive, endocrine
D. Allergy, bleeding, cortisone, diabetes, emboli

Correct answer: D

Rationale: The correct answer is D: 'Allergy, bleeding, cortisone, diabetes, emboli.' The ABCDE mnemonic is used in healthcare to help remember key assessment points. Choice A is incorrect as 'chemicals' and 'dietary' are not part of the ABCDE assessment. Choice B is incorrect as 'cardio' is not part of the ABCDE mnemonic. Choice C is incorrect as 'cardio' and 'digestive' are not part of the ABCDE mnemonic.

3. A nurse working on a med-surg unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?

A. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
B. A client with type 1 DM who uses an insulin pump
C. A client who is receiving heparin and has an aPTT of 34 seconds
D. A client with orthostatic hypotension receiving IV fluids

Correct answer: C

Rationale: The nurse should schedule an interdisciplinary conference for a client who is receiving heparin and has an aPTT of 34 seconds to ensure comprehensive care coordination. In this case, the need for a conference may be to discuss potential adjustments in heparin therapy, monitor for adverse effects, or ensure proper anticoagulation levels. Choices A, B, and D do not specifically indicate the need for interdisciplinary collaboration related to the client's condition or treatment. Therefore, they are not the priority for scheduling an interdisciplinary conference.

4. The doctor has ordered 500 mg of a medication PO once a day. The tablets on hand are labeled as 1 tablet = 250 mg. How many tablets will you administer to your patient?

A. 1 Tablet
B. 2 Tablets
C. 3 Tablets
D. 4 Tablets

Correct answer: B

Rationale: To calculate the number of tablets needed, divide the total dosage prescribed (500 mg) by the dosage per tablet (250 mg per tablet). 500 mg / 250 mg per tablet = 2 tablets. Therefore, the correct answer is 2 tablets. Choices A, C, and D are incorrect as they do not accurately reflect the correct calculation based on the provided information.

5. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the service?

A. A nurse can disclose information to a family member with the client's permission
B. A nurse can apply restraints on an as-needed basis
C. A nurse can administer medications without consent to a client as part of a research study
D. A nurse is responsible for informing clients about treatment options

Correct answer: A

Rationale: The correct statement to include in the in-service about client rights is that a nurse can disclose information to a family member with the client's permission. This respects the client's autonomy and privacy. Choice B is incorrect because restraints should only be applied based on a specific assessment and order, not on an as-needed basis. Choice C is incorrect as administering medications without consent is a violation of ethical principles and legal standards. Choice D is incorrect because while nurses should educate clients about treatment options, the ultimate decision lies with the client after being informed.