A nurse is caring for a client who is at risk for shock. which of the following findings

Hypovolemic shock NCLEX questions for nursing students!

This quiz will test your knowledge on hypovolemic shock. Hypovolemic shock occurs when the intravascular system has been depleted of fluid volume. This causes the cardiac output to fall below the parameters needed to maintain tissue perfusion. This leads to cell hypoxia and eventually multiple organ dysfunction syndrome (MODS) and death.

There are various types of shock: cardiogenic, hypovolemic, anaphylactic, septic, and neurogenic.

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1. True or False: Hypovolemic shock occurs where there is low fluid volume in the interstitial compartment.

Answer: FALSE Hypovolemic shock occurs where there is low fluid volume in the INTRAVASCULAR (not interstitial) system.

2. As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose __________ of their blood volume.

A. <30%

B. >25%

C. >15%

D. >10%

The answer is C. As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose 15% or more of their blood volume.

3. If a patient has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of volume loss this patient has experienced?

A. 25%

B. 40%

C. 30%

D. 10%

The answer is B. This patient has lost 40% of blood volume. Based on this amount of fluid loss, this patient would be in class III (stage 3 of hypovolemic shock). Class III occurs when volume loss is 30-40% or 1,500-2,000 mL in an adult.

4. A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to?

A. An increase in cardiac preload

B. An increase in stroke volume

C. A decrease in cardiac preload

D. A decrease in cardiac contractility

The answer is C. Because there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart (this is the amount of blood draining back to the heart). Hence, this will lead to a DECREASE in preload. Remember preload is the amount the ventricles stretch once their filled with blood. The ventricle won’t be stretching too much because there isn’t enough fluid to fill them. This will decrease stroke volume and in turn decrease cardiac output.

5. True or False: A patient with acute pancreatitis is presenting with Turner and Cullen’s Sign. This patient is at risk for absolute hypovolemic shock.

The answer is FALSE: The statement should read: A patient with acute pancreatitis is presenting with Turner and Cullen’s Sign. This patient is at risk for RELATIVE (not absolute) hypovolemic shock. Relative hypovolemic shock is an INSIDE fluid shift from the intravascular system, which occurs in cases of acute pancreatitis. If a patient has Turner’s Sign (bruising on the flanks) or Cullen’s Sign (bruising around the umbilicus) this can indicate internal hemorrhage and this places the patient at risk for RELATIVE hypovolemic shock. Absolute hypovolemic shock occurs when there is an OUTSIDE fluid shift out of the body from the intravascular system.

6. Select all the conditions below that increases a patient’s risk for absolute hypovolemic shock:

A. Burns

B. Vomiting

C. Long bone fracture

D. Surgery

E. Diarrhea

F. Sepsis

The answers are: B, D, and E. Vomiting, diarrhea, and surgery can all increase the loss of fluid volume outside the body, which are absolute hypovolemic shock types. Burns, long bone fracture, and sepsis can lead to an inside fluid shift of fluid from the intravascular system and are relative hypovolemic shock types.

7. A patient has a 10% loss of their blood volume. Select all the signs and symptoms this patient may present with?

A. Cool, clammy skin

B. Blood pressure within normal limits

C. Anxiety

D. Capillary refill less than 2 seconds

E. Urinary output greater than 30 mL/hr

F. Mild tachycardia

The answers are: B, D, and E. The body can compensate for a volume loss of <15% to maintain cardiac output. Therefore, the patient will be asymptomatic until blood loss is greater than 15% and you would select normal findings for this question, which are: blood pressure within normal limits, capillary refill less than 2 seconds, urinary output greater than 30 mL/hr. Anxiety, cool/clammy skin, and mild tachycardia may present when volume loss is higher.

8. During what stage (or class) of hypovolemic shock does the sympathetic nervous system attempt to maintain cardiac output?

A. I

B. III

C. IV

D. II

The answer is D. During stage 2 or class II of hypovolemic shock, the cardiac output is falling even more due to volume loss. This is when the patient has lost 15-30% of volume. During this time the sympathetic nervous system will take over and attempt to maintain cardiac output.

9. One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply:

\A. Temperature 104.8 ‘F

B. Heart rate 40 bpm

C. Heart rate 140 bpm

D. Anxiety, restlessness

E. Urinary output 15 mL/hr

F. Blood pressure 70/56

G. Pale, cool skin

H. Weak peripheral pulses

I. Blood pressure 220/106

The answers are: C, D, E, F, G, and H. Signs and symptoms of hypovolemic shock include: tachycardia, hypotension, increased respiratory rate, cool/pale/clammy skin, anxiety, decreased urinary output (normal UOP is >30 mL/hr), weak peripheral pulses

10. You’re providing care to a patient who has experienced a 45% loss of their fluid volume and is experiencing hypovolemic shock. The patient has hemodynamic monitoring and fluid resuscitation is being attempted. Which finding indicates the patient is still in hypovolemic shock?

A. Low central venous pressure

B. High pulmonary artery wedge pressure

C. Elevated mean arterial pressure

D. Low systemic vascular resistance

The answer is A. Central venous pressure is the measurement of the pressure in the right atrium and superior vena cava. If fluid volume is low (as in hypovolemic shock) the pressure in this area will also be low. This indicates the patient is still in hypovolemic shock.

11. A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient?

A. Modified Trendelenburg

B. Trendelenburg

C. High Fowler’s

D. Supine

The answer is A. Modified Trendelenburg position is where the patient is supine with their legs elevated at 45 degrees. This will help increase venous return to the heart (hence increase preload), which will help increase cardiac output.

12. A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient’s vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 ‘F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to?

A. Collect a urine sample

B. Obtain an EKG

C. Establish 2 large-bore IV access sites

D. Place a warming blanket on the patient

The answer is C. This patient is at major risk for hypovolemic shock due to the multiple long bone fractures and an internal abdominal injury (this can lead to relative hypovolemic shock…where fluid is loss inside the body). The patient is already showing signs and symptoms of hypovolemic shock. Therefore, it should be a nursing priority to establish IV access (at least two sites should be obtained using a large-bore cannula….18 gauge or higher). Fluids and possibly blood products will need to be given to this patient along with pain medication etc.

13. A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action?

A. Patient heart rate is 115 bpm

B. Patient experiences dyspnea and crackles in lung fields

C. Patient is anxious

D. Patient’s urinary output is 35 mL/hr

The answer is B. When crystalloid fluids are given there is a risk for fluid volume overload even though the patient is hypovolemic, especially with rapid infusions. Therefore, the nurse should monitor the patient for this. If a patient develops difficulty breathing (dyspnea) and has crackles in the lung fields (this represents edema in the lungs), fluid is backing up in the lungs. This requires immediate nursing action. Option A and C are expected finding in hypovolemic shock, and option D is a normal finding…urinary output should be >30 mL/hr.

14. A patient has lost 750 mL of blood volume. The MD orders Normal Saline infusion. Using the 3:1 rule, how much crystalloid solution should be prescribed by the doctor?

A. 2,250 mL of Normal Saline

B. 250 mL of Normal Saline

C. 375 mL of Normal Saline

C. 1,225 mL of Normal Saline

The answer is A. For crystalloid solutions (this includes normal saline and lactated ringer’s), a 3:1 rule is used. This rule states for every 1 mL of approximate blood loss 3 mL of crystalloid solution is given. Therefore, if the patient loses 750 mL of blood, the patient would receive 2,250 mL of saline. 750 x 3 = 2,250

15. You’re providing an in-service to new nurse graduates on the fluid treatment for hypovolemic shock. You ask the participants to list the types of crystalloid solutions used in hypovolemic shock. Which responses are INCORRECT? Select all that apply:

A. Albumin

B. Lactated Ringer’s

C. Normal Saline

D. Hetastarch

The answers are A and D. Albumin and Hetastarch are COLLOID solutions…not crystalloid. Lactated Ringer’s and Normal Saline are considered crystalloid solutions and are used in the treatment of hypovolemic shock.

16. Select all the fluid types below that are considered colloids?

A. Fresh Frozen Plasma

B. Albumin

C. Normal Saline

D. Lactated Ringer’s

E. Hetastarch

F. Platelets

The answers are B and E. These are colloid solutions. Options C and D are considered crystalloid solutions, and options A and F are blood products.

17. Which statement is true about colloid solutions? Select all that apply:

A. These solutions are made up of large molecules that cannot diffuse through the capillary wall, so more fluid stays in the intravascular space longer when compared with the action of a crystalloid solution.

B. These solutions can diffuse through the capillary wall so less fluid stays in the intravascular system when compared to the action of a crystalloid solution.

C. The nurse should monitor for an anaphylactic reaction when these products are administered.

D. These fluids are considered hypertonic solutions.

The answers are A and C. These are true statements about colloid solutions. Options B and D are incorrect.

18. A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to?

A. Rapidly infuse the fluids

B. Warm the fluids

C. Change tubing in between bags

D. Keep the patient supine

The answer is B. It is very important when giving large amount of fluids that the nurse ensures the fluids are warm. WHY? To prevent the patient from developing hypothermia. If this develops, clotting enzymes can become altered along with leukopenia and thrombocytopenia. Keep the patient warm, but not too hot.

19. The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient?

A. Platelets

B. Albumin

C. Fresh Frozen Plasma

D. Packed Red Blood Cells

The answer is C. A patient who needs clotting factors would benefit from fresh frozen plasma (FFP).

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