AH3 Exam 4 Socrative
A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client? A"You might be sedated during the procedure and will not remember what has happened." B"During the procedure, the doctor will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms." C"You will continue to take your medications until the morning of the test." D"This test is a noninvasive method of determining the effectiveness of your medication regimen."
"During the procedure, the doctor will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms." The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmia. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test in order to study the dysrhythmia without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible. Source: Unknown
A 50-year-old man who develops third-degree heart block reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? A"The device delivers a current through your skin that can be uncomfortable." B"The device is inserted through a large vein and threaded into your heart." C"The device uses overdrive pacing to slow the heart to a normal rate." D"The device will convert your heart rate and rhythm back to normal."
"The device delivers a current through your skin that can be uncomfortable." Before initiating transcutaneous pacing (TCP) therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin. Source: Unknown
The nurse is monitoring the ECGs of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action? AA 52-year-old man with premature ventricular contractions (PVCs) that are occurring approximately 12 times a minute. BA 62-year-old man with a fever and sinus tachycardia with a rate of 110 beats/minute CA 42-year-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/minute DA 72-year-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute
A 52-year-old man with premature ventricular contractions (PVCs) that are occurring approximately 12 times a minute. A 52-year-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute Frequent premature ventricular contractions (PVCs) (greater than 1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute MI indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs most likely must be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents. Source: Unknown
Which statement describing systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is accurate?
A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin.
A patient with acute pancreatitis is experiencing hypovolemic shock. Which initial orders for the patient will the nurse implement first? AStart 1000 mL of normal saline at 500 mL/hr. BObtain blood cultures before starting IV antibiotics. CAdminister high-flow oxygen (100%) with a non-rebreather mask. DDraw blood for hematology and coagulation factors.
Administer high-flow oxygen (100%) with a non-rebreather mask. In every type of shock there is a deficiency of oxygen to the cells, and high-flow oxygen therapy is indicated. Fluids would be started next, blood cultures would be done before any antibiotic therapy, and laboratory specimens could also be drawn. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
The nurse is preparing to defibrillate a client on a cardiac monitor who is in ventricular fibrillation. The nurse should do which of the following? AMove the paddle in the nurse's left hand to the midline. BGrasp the handles of the paddles to allow visibility of the black markings on the paddle. CMove the paddle in the nurse's right hand to above the client's nipple. DAfter pressing the charge button and "calling all clear," push the shock button.
After pressing the charge button and "calling all clear," push the shock button. The paddles are in the correct position. The nurse can push the shock button to defibrillate the client. Source: Unknown
A patient's localized infection has progressed and septic shock is suspected. What is an initial treatment modality for this patient? AAdministration of packed red cells BContinuous insulin infusion CIntravenous administration of epinephrine DAggressive fluid resuscitation
Aggressive fluid resuscitation Patients in septic shock require large amounts of fluid replacement. Blood transfusions are most often used in the treatment of patients in hemorrhagic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the initial treatment of septic shock, but it can be used. Source: Unknown
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? AAssess the client's apical pulse and blood pressure. BStart basic cardiopulmonary resuscitation. CPrepare to defibrillate the client. DAdminister amiodarone, an antidysrhythmic, IVP.
Assess the client's apical pulse and blood pressure. The nurse must assess the apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as needed. If the client's heart is still beating, the nurse would likely administer an anti-dysrhythmic. Amiodarone is a drug of choice, but not the first intervention. Defibrillation or CPR may also be needed, but only for pulses VTACH. Source: Colgrove, K. C. (2017). Med-surg success (3rd ed.). Philadelphia, PA: F. A. Davis Company
The ECG monitor of a patient in the cardiac care unit after a myocardial infarction (MI) indicates ventricular bigeminy with a rate of 50 beats/minute. What would be the nurse's next action? AAssess the client's response to the dysrhythmia. BNotify physician of the need for transvenous pacemaker. CAdminister IV amiodarone as prescribed. DPerform immediate defibrillation.
Assess the client's response to the dysrhythmia. A premature ventricular contraction (PVC) is a contraction originating in an ectopic focus in the ventricles. When every other beat is a PVC, the rhythm is called ventricular bigeminy. PVCs are usually a benign finding in the patient with a normal heart. In heart disease, PVCs may reduce the cardiac output and precipitate angina and heart failure, depending on the frequency. Because PVCs in coronary artery disease or acute MI indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Assessment of the patient's hemodynamic status is important to determine whether treatment with drug therapy is needed. Source: Prof D
What physical problems could precipitate hypovolemic shock? Select all that apply. AInsect bites BBurns CAscites DVaccines EHemorrhage
BBurns CAscites EHemorrhage
What is the priority nursing responsibility in the prevention of shock? ATeaching patients health promotion activities to prevent shock. BUsing aseptic technique for all invasive procedures. CBeing aware of the potential for shock in all patients at risk. DFrequently monitoring all patients' vital signs.
Being aware of the potential for shock in all patients at risk. Prevention of shock necessitates identification of persons who are at risk and a thorough baseline nursing assessment with frequent ongoing assessments to monitor and detect changes in patients at risk. Frequent monitoring of all patient' vital signs is not necessary. Aseptic technique for all invasive procedures should always be implemented but will not prevent all types of shock. Health promotion activities that reduce the risk for precipitating conditions, such as coronary artery disease or anaphylaxis, may help to prevent shock in only some cases. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
The nurse would mopnitor a client beginning drug therapy with sotalol (Betapace) for which of the following life-threatening manifestations of an adverse drug reaction? AHives and wheezing BAtrioventricular AV block, hypotension CBradycardia, chest pain, dyspnea DEarly signs of a cerebrovascular accident (CVA)
Bradycardia, chest pain, dyspnea Sotalol is a beta-adrenergic blocking agent resulting in side effects such as bradycardia, dyspnea, and chest pain. Because of the decreased conduction between the SA node and the AV node, AV block and hypotension are more common with calcium channel blockers rather than beta blockers. Hives and wheezing are associated with a anaphylactic reation, but that is not common with beta blockers.
A patient with a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the patient for early organ damage associated with MODS, what is most important for the nurse to assess? ABreath sounds. BCentral venous pressure. CUrine output. DPeripheral circulation.
Breath sounds. Generally, the first body system affected by MODS is the respiratory system. Adventitious sounds and areas with absent breath sounds will be present. Other organ damage occurs, but the lungs are usually the first. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
What is the priority nursing responsibility in the prevention of shock? AFrequently monitoring all patients' vital signs. BUsing aseptic technique for all invasive procedures. CBeing aware of the potential for shock in all patients at risk. DTeaching patients health promotion activities to prevent shock.
CBeing aware of the potential for shock in all patients at risk.
What should the nurse assess the patient for during administration of IV norepinephrine (Levophed)? AHypotension. BMarked diuresis. CMetabolic alkalosis. DDecreased tissue perfusion.
Decreased tissue perfusion. As a vasopressor, norepinephrine may cause severe vasoconstriction, which would further decrease tissue perfusion, especially if fluid replacement is inadequate. Vasopressors generally cause hypertension, reflex bradycardia, and decreased urine output because of decreased renal blood flow. They do not directly affect acid-base balance. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
The nurse is caring for a client in cardiogenic shock. Which treatments are appropriate for this patient? Select all that apply. ACorticosteroids to stabilize cell walls in the infarcted myocardium. BTrendelenburg positioning to facilitate venous return and increase preload. CCirculatory assist devices such as an intraaortic balloon pump. DVasopressors to increase systemic vascular resistance. EDobutamine (Dobutrex) to increase myocardial contractility.
Dobutamine (Dobutrex) to increase myocardial contractility. Circulatory assist devices such as an intraaortic balloon pump. Dobutamine (Dobutrex) is used in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart may be reduced in cardiogenic shock with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device. Source: Unknown
The nurse assess that a client is at risk for developing disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings should be reported to the physician immediately? AProthrombin time (PT) 11 seconds BFibrinogen level 110 mg/dL CHemoglobin 15 grams/dL DPartial thromboplastin time (PTT) of 30 seconds
Fibrinogen level 110 mg/dL A normal fibrinogen level is 140 to 400 mg/dL in adults. A decreased fibrinogen level indicates excessive usage of fibrinogen during the clotting process. Normal hemoglobin ranges from 12 to 17 depending on gender. PT is normally 10 to 14 seconds. Normal PTT is 25 to 35 seconds. Source: Nugent, P. M. & Vitale, B. A. (2008). Fundamentals success (2nd ed.). Philadelphia, PA: F.A. Davis Company
The patient has hypokalemia, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm; the P wave is 0.06 seconds (sec) and normal shape; the PR interval is 0.24 sec; the QRS is 0.09 sec. How should the nurse document this rhythm? AFirst-degree AV block BPremature atrial contraction (PAC) CSecond-degree AV block DPremature ventricular contraction (PVC)
First-degree AV block The PR interval is greater than 0.20 which indicates a first degree AV block. Source: Prof D
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a pulse of 110 and a BP of 92/60. Which type of shock should the nurse suspect? ANeurogenic shock. BSeptic shock. CHypovolemic shock. DCardiogenic shock.
Hypovolemic shock. These client's signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging. Source: Colgrove, K. C. (2017). Med-surg success (3rd ed.). Philadelphia, PA: F. A. Davis Company
The nurse observes that a client is being monitored is in ventricular fibrillation. The first action should be to do which of the following? AAdminister sodium bicarbonate for developing acidosis. BInitiate cardiopulmonary resuscitation (CPR). CImmediately defibrillate the client with 200 joules. DAdminister oxygen.
Immediately defibrillate the client with 200 joules. Defibrillation is the definitive treatment for this life-threatening arrhythmia when a defibrillator is immediately accessible. CPR would be used if defibrillation is not successful in converting this arrythmia. Oxygen should be administered but does not take priority over defibrillation. Sodium bicarbonate is used to treat acidosis that may develop with prolonged CPR, but is not priority. Source: Nugent, P. M. & Vitale, B. A. (2008). Fundamentals success (2nd ed.). Philadelphia, PA: F.A. Davis Company
What is the key factor in describing any type of shock? AHypotension BInadequate tissue perfusion CHypoxemia DVascular Collapse
Inadequate tissue perfusion Although all of the factors may be present, regardless of the cause, the end result is inadequate supply of oxygen and nutrients to body cells from inadequate tissue perfusion. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
A patient in shock has a nursing diagnosis of fear related to severity of condition and perceived threat of death as manifested by verbalization of anxiety about condition and fear of death. What is an appropriate nursing intervention for this patient? AInform the patient of the current plan of care and its rationale. BCall a member of the clergy to visit the patient. CAdminister antianxiety agents. DAllow caregivers to visit as much as possible.
Inform the patient of the current plan of care and its rationale.
A patient with severe trauma has been treated for hypovolemic shock. The nurse recognizes that the patient is in the refractory stage of shock when what is found during assessment? AProfound vasoconstriction with absent peripheral pulses. BA respiratory alkalosis. CMarked hypotension and refractory hypoxemia. DUnresponsiveness that responds only to painful stimuli.
Marked hypotension and refractory hypoxemia. During both the compensatory and progressive stages of sock, the SNS is activated in an attempt to maintain CO and SVR. In the refractory stage of shock, the SNS can no longer compensate to maintain homeostasis and a loss of vasomotor tone leading to profound hypotension affects perfusion to all vital organs, causing increasing cellular hypoxia, metabolic acidosis, and cellular death. Respiratory alkalosis occurs in early shock. Unresponsiveness and absent peripheral pulses can occur for many reasons, including in earlier shock. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
The patient has an electrocardiographic (ECG) tracing that is 50 beats/minute, the rhythm is regular, and there is a P wave before every QRS complex. The QRS has a normal shape and duration, and the PR interval is normal. What is your response? AAttach an external pacemaker. BAdminister epinephrine by IVP. CMonitor the patient for syncope. DAdminister atropine by intravenous push (IVP).
Monitor the patient for syncope. The rhythm described is sinus bradycardia. Treatment depends on the patient's response and whether adequate perfusion is occurring. If the patient tolerates the rhythm, no treatment is given. Source: UNKOWN
The nurse is caring for a client admitted with dehydration and hypotension for a several day period prior to admission. What finding is most important to report to the physcian? AApical pulse of 106 bpm. BNew onset of confusion and lethargy. CDecreased bowel sounds. DCool and slightly pale distal extremities.
New onset of confusion and lethargy. New onset of confusion and letharty (really, any LOC change) indicates the client is progressing into the progressive stage of shock and requires close attention and new orders. The other signs and symptoms are expected in beginning shock stage of a client with the history presented (cool extremities, tachycardia, and decreased bowel sounds). Source: Prof D
The nurse is planning care for clients on the telemetry unit. Which action is appropriate to assing to the experienced unlicensed assistice personnel (UAP) on the unit? AObserve the cardiac rhythms on monitoring. BDecide whether a client with a HR of 117 needs additional assessment. CAssess the blood pressure of a client being started on an IV infusion of nicardipine. DMonitor the client's level on consciousness that is receiving electrocardioversion.
Observe the cardiac rhythms on monitoring. On a telemetry unit, a UAP is trained to act as a monitor tech to observe the telemetry monitor and notify the RN of issues. While vital signs are normally appropriate, the nurse would not assign this task for an unstable client. Source: Prof D
When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be? AHypovolemic shock. BDistributive shock. CCardiogenic shock. DObstructive shock.
Obstructive shock. Obstructive shock occurs when a physical obstruction impedes the filling or outflow of blood, resulting in reduced cardiac output (CO). Distributive shock is evident with massive vasodilation and impaired cellular metabolism (neurogenic shock) or increased capillary permeability (Anaphylactic shock). Cardiogenic shock occurs when the systolic or diastolic dysfunction of the heart's pumping action results in reduced CO. Hypovolemic shock is the absolute or relative loss of blood or fluid. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
The client has been defibrillated unsuccessfully three times using an automatic external defibrillator (AED). The nurse determines that which action should be taken next? APerform cardiopulmonary resuscitation (CPR) for 1 minute, then defibrillate up to three more times at 360 joules. BAdminister sodium bicarbonate intravenously and resume defibrillation attempts. CDefibrillate one more time, then terminate the resuscitation effort. DPerform CPR for 5 minutes, then defibrillate three more times at 400 joules.
Perform cardiopulmonary resuscitation (CPR) for 1 minute, then defibrillate up to three more times at 360 joules. After three unsuccessful defibrillation attempts, CPR should be done for 1 minute, followed by 3 more shocks if they are needed, each delivered at 360 joules. It is critically important that advanced care life support (ACLS) become available as soon as possible. Source: Silvestri, L. A. (n.d.). Saunders Q&A review cards for the NCLEX-RN exam.
Which of the following nursing actions provides for the safest environment during a defibrillation attempt for ventricular tachycardia (VTACH)? AEnsuring that no lubricant is on the paddles. BPerforming a visual and verbal check that all assisting personnel are clear of the client and the client's bed. CPlacing the charged paddles one at a time on the client's chest. DHolding the client's upper torso stable while the defibrillation is performed.
Performing a visual and verbal check that all assisting personnel are clear of the client and the client's bed. Safety during defibrillation is essential for preventing injury to the client and to the personnel assisting with the procedure. The person performing the defibrillation (hitting the button) assures that all personnel are standing clear of the bed by a verbal and visual check of "all clear." For the shock to be effective, some type of conductive medium (lubricant) must be places between the paddles and the skin. Both paddles are placed on the client's chest at the same time. Source: Elsevier (2012) Rntertainment: The NCLEX examination review game (2nd ed). Maryland Heights, MO: Elseview Mosby (Safe and Effective Care, Q52)
The nurse is caring for a client in monomorphic ventricular tachycardia (VTACH). They are currently hemodynamically stable. What medications does the nurse anticipate the physician ordering? Select all that apply. AAdenosine BProcainamide CSotalol DAmiodarone EAtropine
Procainamide Amiodarone Sotalol The three medications that a client would likely receive for ventricular tachycardia are procainamide, amiodarone, and sotalol. Diltiazem (Cardizem) is a medication that is normally used for atrial type dysrhythmias. Source: prof D
A 70-year old patient is malnourished, has a history of type 2 diabetes, and is admitted from the nursing home with pneumonia and tachypnea. For which kind of shock should the nurse closely monitor this patient? ANeurogenic shock BCardiogenic shock CSeptic shock DAnaphylactic shock
Septic Older adults with chronic diseases and malnourished or debilitated patients are at risk of developing septic shock, especially when they have an infection (e.g., pneumonia, urinary tract infection) or indwelling lines or catheters. Fever, hypothermia, tachycardia, tachypnea, altered mental status, significant edema, or hyperglycemia without diabetes are also criteria for diagnosis of sepsis. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? AObtain arterial blood gas (ABG). BStart an IV with an 18-guage catheter. CAdminister dopamine intravenous infusion. DInsert an indwelling urinary catheter.
Start an IV with an 18-guage catheter. There are many types of shock, but the one common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock. Fluid resuscitation would be first, then followed by some of the other interventions listed. Source: Colgrove, K. C. (2017). Med-surg success (3rd ed.). Philadelphia, PA: F. A. Davis Company
The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. APrepare to administer the antidysrhythmic adenosine IVP. BPrepare to administer the antidysrhythmic amiodarone IVP. CStart cardiopulmonary resuscitation. DPrepare to defibrillate the client. EBring the crash cart to the bedside.
Start cardiopulmonary resuscitation. Prepare to defibrillate the client. Bring the crash cart to the bedside. Prepare to administer the antidysrhythmic amiodarone IVP. The client will need the crash cart, the defibrillator, and CPR. Amiodarone can be given as the code progresses. Adenosine is not an antidysrhythmic that helps with Vfib. Source: Colgrove, K. C. (2017). Med-surg success (3rd ed.). Philadelphia, PA: F. A. Davis Company
What intervention is of primary importance in a patient with septic shock? AStart two 14-gauge intravenous (IV) access lines. BObtain an electrocardiogram (ECG). CAdminister norepinephrine (Levophed). DMeasure the mean arterial pressure (MAP).
Start two 14-gauge intravenous (IV) access lines. Except for cardiogenic and neurogenic shock, all other types of shock involve decreased circulating blood volume. The cornerstone of therapy for septic shock is volume expansion. Insert two large-bore (14- to 16-gauge) IV catheters, and then administer crystalloids (normal saline) and colloids (albumin) for fluid resuscitation. Source: Unknown
When caring for a patient in cardiogenic shock, the nurse recognizes that the metabolic demands of turning and moving the patient exceed the oxygen supply when what change is revealed in hemodynamic monitoring? ACO from 4.2 L/min to 4.8 L/min. BStroke volume (SV) from 52 to 68 mL/beat. CSvO2 from 62% to 54%. DSVR from 1300 dyne/sec/cm5 to 1120 dyne/sec/cm5.
SvO2 from 62% to 54%. A decreased mixed venous oxygen saturation indicates the patient has used the venous oxygen reserve and is at greater risk for anaerobic metabolism. The SvO2 decreased when more oxygen is used by the calls, as in activity or hypermetabolism. All of the other values indicate an improvement in the patient's condition. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
The nurse is preparing discharge instructions to a client with a newly inserted permanent pacemaker. Which teaching points should the nurse include in the education? Select all that apply. AAvoid or eliminate all air travel. BAvoid microwave ovens because they interfere with pacemaker function. CTake and record a pulse rate daily. DAvoid lifting the arm on the side of the pacemaker above the shoulder. EObtain and wear a Medic Alert ID or bracelet at all times.
Take and record a pulse rate daily. Obtain and wear a Medic Alert ID or bracelet at all times. Avoid lifting the arm on the side of the pacemaker above the shoulder. Air travel is not restricted. Inform airport security about the pacemaker because it may set off the metal detector. If a hand-held screening wand is used, it should not be placed directly over the pacemaker. Manufacturer information may vary regarding the effect of metal detectors on the function of the pacemaker. The patient should monitor the pulse and inform the primary care provider if it drops below predetermined rate. A Medic Alert ID or bracelet should be worn at all times. The patient should avoid lifting the arm on the pacemaker side above the shoulder until it is approved by the primary care provider. Microwave ovens are safe to use and do not interfere with pacemaker function. Table 36-13 provides additional discharge teaching guidelines for a patient with a pacemaker. Source: Prof D
The nurse is caring for a patient in cardiogenic shock brought on by cardiomyopathy. Which order received from the physician would the nurse expect? ATitrate vasopressin drip to maintain systolic blood pressure greater than 90. BTitrate nicardipine infusion for a blood pressure of between 110 and 140 systolic. CAdminister 2 liters 0.9% sodium chloride solution. DAdminister IM epinephrine STAT.
Titrate nicardipine infusion for a blood pressure of between 110 and 140 systolic. In cardiogenic shock, the goal is to increase contractility of the heart, reduce preload, and reduce afterload, which is a function of dobutamine. Of the choices given, the nurse would likely get an order for afterload reduction. In addition, vasopressin is not something that is normally titrated.
The patient is receiving aggressive fluid resuscitation. Which is the best indicator that the patient's cardiac output is adequate? ASystolic blood pressure BUrine output CSodium (Na+) serum level DBlood urea nitrogen (BUN) level
Urine output Although blood pressure helps to determine whether the patient's cardiac output is adequate, an assessment of end-organ perfusion (e.g., urine output, neurologic function, peripheral pulses) provides more relevant information regarding the adequacy of the cardiac output. Source: Unknown
The nurse is working with a client admitted with shock in a critical care unit. What assessment findings indicate fluid volume deficit and would need to be reported to the health care provider? Select all that apply. AMean arterial pressure of 55 mmHg. BUrine output of 40 mLs for the last two hours. CHeart rate 136 beats per minute. DOxygen saturation of 60%. ECentral venous pressure 1 mmHg
Urine output of 40 mLs for the last two hours. Heart rate 136 beats per minute. Central venous pressure 1 mmHg Fluid volume deficit symptoms include low urine output > 60 in two hours, central venous pressure less than 3, and rapid pulse > 100. The client's oxygen saturation of 65% and mean arterial pressure of 55 mmHg indicate low oxygenation and will not be changed with fluid orders
The nurse is preparing the client for cardioversion. The nurse should do which of the following? Select all that apply. AExert 5 to 10 lb of pressure on each paddle to ensure good skin contact. BRecord the delivered energy and the resulting rhythm. CUse a conducting agent between the skin and the paddles. DCall "clear" before discharging the electrical current. EPlace the paddles over the client's clothin
Use a conducting agent between the skin and the paddles. Call "clear" before discharging the electrical current. Record the delivered energy and the resulting rhythm. A conducting agent is placed between the skin and the paddles to conduct the electrical current when discharged. The nurse must make sure to call "clear" before discharging the electrical current to prevent injury to others who may be helping with the client. Each paddle is placed directly on the conductive pads that are on the client's skin. Applying approximately 20 to 25 lb of pressure on each paddle is recommended to ensure good skin contact. The nurse must record the amount of electrical current delivered and the resulting rhythm. Source: Unknown
The patient has a heart rate of 40 beats/minute. The P waves are regular, and the Q waves are regular, but there is no relationship between the P wave and QRS complex. What treatment do you anticipate? AUtilizing emergency pacemaker. BContinue to monitor the patient. CPrepare for cardioversion. DPerform carotid massage.
Utilizing emergency pacemaker. In third-degree atrioventricular (AV) block, there is no correlation between the impulse from the atrium to the ventricles and the ventricular rhythm seen. A pacemaker eventually is required. Action must be taken because this usually results in reduced cardiac output with subsequent ischemia if untreated. Carotid massage is vagal stimulation, and it can cause bradycardia. There is a problem in conduction, not abnormal contraction, and defibrillation is not used. Source: Unknown.
A patient with a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the patient for early organ damage associated with MODS, it is most important for the nurse to assess Acentral venous pressure. Bperipheral circulation. Curine output. Dlung sounds.
lung sounds. Rationale: Generally, the first organ system affected by mediator-induced injury in MODS is the respiratory system. Adventitious sounds and areas absent of breath sounds will be present. Other organ damage also occurs, but lungs are usually first. Source: Prof D
When administering any vasoactive drug during the treatment of shock, the nurse knows that the goal of the therapy is to
maintain a MAP of at least 60 mm Hg. Rationale: Vasoactive drugs are those that can either dilate or constrict blood vessels, and both are used in various stages of shock treatment. When using either vasodilators or vasoconstrictors, it is important to maintain a MAP of at least 60 mm Hg so that adequate perfusion is maintained. Source: Unknown
The nurse suspects sepsis as a cause of shock when the laboratory test results indicate: Aincreased blood urea nitrogen. Bthrombocytopenia. Chypokalemia. Ddecreased hemoglobin.
thrombocytopenia. Thrombocytopenia can occur. When sepsis is the cause of shock, endotoxin stimulates a cascade of inflammatory responses that start with the release of tumor necrosis factor (TNF) and interleukin-1 (IL-1), which stimulate other inflammatory mediators. The release of platelet-activating factor causes formation of microthrombi and vessel obstruction. There is vasodilation, increased capillary permeability, neutrophil and platelet aggregation, and adhesion to the endothelium. The process does not occur in other types of shock until late stages of shock. Source: Sandstrom, S. A. (2017). Study guide for medical-surgical nursing (10th ed). St. Louis, MO: Elsevier
