Ch 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

d) Bronchioles relax Pg. 283 When beta-2 adrenergic receptors are stimulated, vasodilation occurs in the heart and skeletal muscles, and the bronchioles relax.

54. When beta-2 adrenergic receptors are stimulated which of the following occur? a) Bronchioles constrict b) Vasoconstriction in heart c) Vasoconstriction in skeletal muscles d) Bronchioles relax

d) Organ damage Pg. 274 When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.

18. A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? a) Weight loss b) Unsteady gait c) Liver dysfunction d) Organ damage

b) Dextran Pg. 286 Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

1. A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is a) Plasma b) Dextran c) Salt-poor albumin d) Packed red blood cells

c) Decompensation (Progressive) Pg. 280 The decompensation or progressive stage occurs as compensatory mechanisms fail. The client's condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.

19. At what point in shock does metabolic acidosis occur? a) Irreversible b) Early c) Decompensation (Progressive) d) Late

b) Modified Trendelburg Pg. 285 The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.

10. A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? a) Semi-Fowler's b) Modified Trendelenburg c) Supine d) Trendelenburg

a) The right foot is cooler than the left foot Pg. 289 When a client has an intra-aortic balloon counterpulsation, he or she is at risk for circulatory problems in the leg in which the catheter has been inserted. In this case, it is the right leg. A complication would be a right foot that is cooler than the left foot. Pedal pulses of 1+ bilaterally would not be a complication of this therapy but of other problems. The balloon is supposed to deflate prior to systole. It is normal for vesicular breath sounds to be audible in the lung periphery.

2. A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: a) The right foot is cooler than the left foot b) Vesicular breath sounds are audible in the lung periphery c) Bilateral pedal pulses are 1+ d) The balloon deflates prior to systole

c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Pg. 284 The Centers for Disease Control and Prevention do not recommend hanging tape on bedside tables, siderails, linens, or clothing to use for dressings. The other options are activities that are proper infection control practices.

20. A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? a) Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids b) Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing d) Rubbing the hands together with antiseptic solution until dry when exiting the client's room

b) Compensatory stage Pg. 276 In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure.

26. The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? a) Progressive stage b) Compensatory stage c) Initial stage d) Irreversible stage

d) 60 mm Hg Pg. 275 Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.

27. The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. a) 80 mm Hg b) 90 mm Hg c) 70 mm Hg d) 60 mm Hg

b) Mean arterial pressure of 70 mm Hg Pg. 276-277 The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

3. The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? a) ScvO2 of 60% b) Mean arterial pressure of 70 mm Hg c) Central venous pressure of 6 mm Hg d) Urine output of 0.2 mL/kg/hr

b) Distributive Pg. 274 The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. This makes options A, C, and D incorrect.

31. The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock? a) Cardiotonic b) Distributive c) Restrictive d) Hypervolemic

a) Narrowed pulse pressure Pg. 277 Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.

38. The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? a) Narrowed pulse pressure b) Increase in systolic blood pressure c) Decrease in respiratory rate d) Increase in diastolic blood pressure

b) Lung sounds Pg. 282 The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

44. A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess a) Skin perfusion b) Lung sounds c) Bowel sounds d) Mental status

b) Constrict blood vessels in the cardiorespiratory system Pg. 283 Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

53. A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: a) Vasodilate the skeletal muscles b) Constrict blood vessels in the cardiorespiratory system c) Relax the bronchioles d) Decrease heart rate

c) A rapid, bounding pulse Pg. 292 A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.

4. The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? a) A slow but steady pulse b) A weak and thready pulse c) A rapid, bounding pulse d) A slow and imperceptible pulse

c) Septic Pg. 292 In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.

40. The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? a) Neurogenic b) Cardiogenic c) Septic d) Anaphylactic

b) Maintain activity restriction to bedrest Pg. 290 Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.

41. The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? a) Limit interaction with visitors b) Maintain activity restriction to bedrest c) Arrange personal care supplies nearby d) Avoid heavy meals

a) Hypovolemic shock; blood loss c) Cardiogenic shock; myocardial infarction d) Anaphylactic shock; nut allergy e) Septic shock; infection Pg. 273 Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interfere in blood flow through the heart . Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.

42. A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply. a) Hypovolemic shock; blood loss b) Obstructive shock; kidney stone c) Cardiogenic shock; myocardial infarction d) Anaphylactic shock; nut allergy e) Septic shock; infection f) Neurogenic shock; diabetes

a) Administer intravenous fluids c) Monitor for changes in vital signs d) Identify the cause of shock Pg. 277 Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. a) Administer intravenous fluids b) Administer prophylactic packed red blood cells c) Monitor for changes in vital signs d) Identify the cause of shock e) Administer vasoconstrictive medications

a) 15 min Pg. 283 When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).

37. When vasoactive medications are administered, the nurse must monitor vital signs at least how often? a) 15 min b) 30 min c) 1 hr d) 4 hr

b) Progressive Pg. 279 In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.

32. Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? a) Refractory b) Progressive c) Compensatory d) Irreversible

d) An older adult man with end-stage renal disease and an infected dialysis access site Pg. 297 MODS may develop when a client experiences septic shock. Those at increased risk for MODS are older clients, clients who are malnourished, and clients with coexisting disease.

11. A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is a) A middle-aged woman with metastatic breast cancer and a BMI of 26 b) An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection c) A young female adolescent who developed shock from tampon use during menses d) An older adult man with end-stage renal disease and an infected dialysis access site

a) 70% Pg. 278 Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.

12. The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? a) 70% b) 60% c) 40% d) 50%

d) Decompensation stage Pg. 280 Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. This client's symptoms, particularly the dropping BP, indicate the decompensation stage. During the compensation stage of shock, physiologic mechanisms attempt to stabilize the spiraling consequences. During the irreversible stage, the client no longer responds to medical interventions, and multiple systems begin to fail. Cardiogenic shock is a type of shock.

13. A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing? a) Cardiogenic shock b) Irreversible stage c) Compensation stage d) Decompensation stage

c) Head injury Pg. 286 An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.

14. Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Diabetes b) Myocardial infarction c) Head injury d) Multiple sclerosis

a) Encourage the family to touch and talk to the client Pg. 281 The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

15. A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to a) Encourage the family to touch and talk to the client b) Inform the family that everything is being done to assist with the client's survival c) Open up discussion among the family members about nursing home placement d) Contact a spiritual advisor to provide comfort to the family

b) Dehydration d) Burns Pg. 285 The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

16. The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. a) Diarrhea b) Dehydration c) Vomiting d) Burns e) Trauma

b) Jugular venous distention Pg. 287 When administering large volumes of fluid replacement, the nurse monitors the client for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. The nurse assesses for jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. The client should exhibit vesicular breath sounds.

17. A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: a) Positive increase in the fluid balance ratio b) Jugular venous distention c) Decreased pulse rate to 110 beats/minute d) Vesicular breath sounds

a) Anaphylactic Pg. 296 During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.

21. Which type of shock occurs from an antigen-antibody response? a) Anaphylactic b) Cardiogenic c) Septic d) Neurogenic

b) Use strict hand hygiene techniques Pg. 292 The incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques. Inserting an indwelling catheter would increase the risk of infection and thus of septic shock, not decrease it. Hand hygiene is more of a priority than administering prophylactic antibiotics. Masks would not prevent many types of infections.

22. What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? a) Insert indwelling catheters for incontinent patients b) Use strict hand hygiene techniques c) Administer prophylactic antibiotics for all patients at risk d) Have patients wear masks in the health care facility

b) Brain Pg.276 The body displays a "fight-or-flight" response, with the release of catecholamines. Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.

23. During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? a) Liver b) Brain c) Kidneys d) Lungs

a) Increase the force of myocardial contraction Pg. 288 The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.

24. The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? a) Increase the force of myocardial contraction b) Slow the heart rate c) Depress the central nervous system d) Dilate the bronchial tree

b) Aorta Pg. 275 Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall.

25. When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a) Radial artery b) Aorta c) Right ventricular wall d) Brachial artery

a) Blood pressure Pg. 277 By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

28. Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: a) Blood pressure b) Heart rate c) Renal output d) Breath sounds

a) Distributive Pg. 290 Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.

33. The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? a) Distributive b) Carcinogenic c) Hypovolemic d) Obstructive

a) Apply clean gloves before accessing the line port b) Perform a 10-second "hub scrub" using chlorhexidine and friction in a twisting motion on the access hub d) Always perform hand hygiene before manipulating or accessing the line ports Pg. 283-284 The following nursing interventions are essential to reduce the risk of infection: maintain sterile technique when changing the central venous line dressing; always perform hand hygiene before manipulating or accessing the line ports; apply clean gloves before accessing the line port; and perform a 15- to 30-second "hub scrub" using chlorhexidine or alcohol and friction in a twisting motion on the access hub. The latter reduces biofilm on the hub that may contain pathogens.

29. The nurse is caring for a client with a central venous line in place for the treatment of shock. Which nursing interventions are essential for the nurse to complete in order to reduce the risk of infection? Select all that apply. a) Apply clean gloves before accessing the line port b) Perform a 10-second "hub scrub" using chlorhexidine and friction in a twisting motion on the access hub c) Maintain sterile technique when changing the central venous line dressing d) Always perform hand hygiene before manipulating or accessing the line ports e) Instruct the client to wear a face mask and gloves while the central venous line is in place

d) Increase cardiac output Pg. 288 Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.

30. What is the major clinical use of dobutamine? a) Treat hypotension b) Treat hypertension c) Prevent sinus bradycardia d) Increase cardiac output

c) Adventitious breath sounds Pg. 290 The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.

34. A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits a) Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute b) Troponin levels less than 0.35 ng/mL c) Adventitious breath sounds d) A change in apical pulse rate from 102 to 88 beats/min

b) Neurogenic shock Pg. 296 Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections. Anaphylactic shock is a subcategory of distributive shock, but it is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive, such as bee venom, latex, fish, nuts, and penicillin. Hypovolemic shock is not a subcategory of distributive shock. It occurs when the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma.

35. A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? a) Septic shock b) Neurogenic shock c) Hypovolemic shock d) Anaphylactic shock

d) Levophed Pg. 285 The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.

36. The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered? a) Nipride b) Methotrexate c) Dobutrex d) Levophed

a) Disseminated intravascular coagulation (DIC) Pg. 280 Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (e.g., prothrombin time [PT], activated partial thromboplastin time [aPTT]) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. The other conditions listed would not result in bleeding simultaneously at multiple sites.

39. The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? a) Disseminated intravascular coagulation (DIC) b) Septicemia c) Stress ulcer d) Steven-Johnson syndrome

b) It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate Pg. 273 Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Respiratory distress syndrome can be a complication of shock but is not necessarily caused by shock. Shock does not begin when peripheral blood flow is inadequate. Not every trauma victim goes into shock.

47. The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? a) It causes respiratory distress syndrome b) It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate c) It is a component of any trauma d) It begins when peripheral blood flow is inadequate

b) A myocardial infarction Pg. 287 Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

43. A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: a) Cardiomyopathies b) A myocardial infarction c) Arrhythmias d) Valvular damage

b) Oxygen at 2 L/min by nasal cannula Pg. In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

45. A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: a) NS at 60 mL/hr via an intravenous line b) Oxygen at 2 L/min by nasal cannula c) Morphine 2 mg intravenously d) Dopamine (Intropin) intravenous solution

b) Sodium and glucose levels Pg. 277 In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines.

46. The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines? a) BUN and creatinine b) Sodium and glucose levels c) Myoglobin and CK-MB d) T3 and T4

b) Sodium nitroprusside Pg. 283 Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.

48. Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as a) Furosemide b) Sodium nitroprusside c) Dopamine d) Norepinephrine

a) The difference between the systolic and diastolic pressure Pg. 277 The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.

49. The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following? a) The difference between the systolic and diastolic pressure b) The difference between an upper extremity and lower extremity blood pressure c) The difference between the arterial and venous blood pressure d) The difference between an apical and radial pulse

a) Dobutamine b) Nitroglycerin c) Vasopressin d) Dopamine Pg. 289 Dopamine is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. It may be used with dobutamine and nitroglycerin to improve tissue perfusion. Dobutamine produces inotropic effects by stimulating myocardial beta-receptors, increasing the strength of myocardial activity and improving cardiac output. Myocardial alpha-adrenergic receptors are also stimulated, resulting in decreased pulmonary and systemic vascular resistance. Intravenous nitroglycerin in low doses acts as a venous vasodilator and reduces preload. At higher doses, nitroglycerin causes arterial vasodilation and reduces afterload as well. These actions, in combination with dobutamine, increase cardiac output while minimizing cardiac workload. In addition, vasodilation enhances blood flow to the myocardium, improving oxygen delivery to the weakened heart muscle. In addition, vasopressin is another agent used to manage cardiogenic shock. Diphenhydramine is indicated in anaphylactic shock rather than cardiogenic shock, and can be given intravenously to reverse the effects of histamine.

5. A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply. a) Dobutamine b) Nitroglycerin c) Vasopressin d) Dopamine e) Diphenhydramine

c) Raise the head of the client's bed Pg. 282 Normal abdominal pressures are 0 to 5 mm Hg. The client may be experiencing abdominal compartment syndrome, an increase in the pressure of the abdominal cavity. This is from fluid leaking into the intra-abdominal cavity and results in elevating the client's diaphragm. Raising the head of the bed will promote easier breathing. The other options may be done by the nurse, but ensuring adequate oxygenation is the priority.

50. A client experienced hemorrhage following a gunshot to the chest and received massive amounts of fluids. The client is now stable. The nurse assesses abdominal pressure as 12 mm Hg. The most immediate nursing intervention is to a) Begin measurements of abdominal girth b) Turn the client every 2 hours c) Raise the head of the client's bed d) Insert a rectal tube for decompression

b) A continuous infusion of total parenteral nutrition Pg. 294 Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.

51. A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A full liquid diet b) A continuous infusion of total parenteral nutrition c) Isotonic enteral nutrition every 6 hours d) An infusion of crystalloids at an increased rate of flow

b) Reduces preload Pg. 208 In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).

52. Morphine sulfate has which of the following effects on the body? a) No effect on preload or afterload b) Reduces preload c) Increases preload d) Increases afterload

d) In the compensation stage, catecholamines are released Pg. 276 Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage.

55. You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? a) Shock begins in the decompensation stage b) The renin-angiotensin-aldosterone system fails in the compensation stage c) Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage d) In the compensation stage, catecholamines are released

a) 300 mL Pg. 279 An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria.

56. The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition? a) 300 mL b) 500 mL c) 600 mL d) 400 mL

c) The patient has developed a stress ulcer that is bleeding Pg. 279 GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus.

57. The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient? a) The patient is having a reaction to the vasoconstricting medications b) The patient has a tumor in the esophagus c) The patient has developed a stress ulcer that is bleeding d) The patient has bleeding esophageal varices

b) Decreased blood pressure Pg. 285 A potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently according to the manufacturer's recommendation and institutional policy.

58. What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? a) Reduced preload b) Decreased blood pressure c) Increased cardiac output d) Reduced afterload

d) Administer norepinephrine as prescribed Pg. 291-293 Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.

59. The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? a) Initiate enteral feedings as prescribed b) Begin a continuous IV infusion of insulin per protocol c) Administer recombinant human activated protein C (rhAPC) as prescribed d) Administer norepinephrine as prescribed

a) Famotidine (Pepcid) b) Lansoprazole e) Nizatidine Pg. 284-285 Antacids, H2 blockers (Pepcid, Axid), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Desmopressin (DDVAP) is used in the treatment of diabetes insipidus. Furosemide (Lasix) is a loop diuretic and does not prevent ulcer formation.

6. Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a) Famotidine (Pepcid) b) Lansoprazole c) Furosemide d) Desmopressin e) Nizatidine

c) Lactated Ringer's Pg. 282 Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

60. The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? a) 0.9% sodium chloride b) Albumin c) Lactated Ringer's d) Dextran

b) Neurogenic Pg. 296 The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.

61. Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? a) Cardiogenic b) Neurogenic c) Anaphylactic d) Septic

a) Obtain the lactate level b) Administer oxygen therapy c) Monitor temperature Pg. 102 The nurse should expect to administer oxygen therapy to support perfusion, monitor temperature to assess metabolic response, and obtain lactate levels, which serve as a critical predictor of the client's metabolic stress response. The nurse should not place a client with septicemia in a prone position because this would lead to further respiratory compromise. The nurse should not increase PO fluid intake because this would also lead to respiratory compromise and fluid volume overload.

63. A nurse is assessing a client who is experiencing significant stress due to septicemia. The nurse should _______, _______, and _________. a) Obtain the lactate level b) Administer oxygen therapy c) Monitor temperature d) Maintain prone position e) Increase oral (PO) fluid intake

b) Disseminated intravascular coagulation (DIC) c) Kidney failure e) Acute respiratory distress syndrome Pg. 279 When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.

64. A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. a) GERD b) Disseminated intravascular coagulation (DIC) c) Kidney failure d) Hypoglycemia e) Acute respiratory distress syndrome

c) Cold, clammy skin and tachycardia Pg. 274 In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident.

65. The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by: a) A systolic blood pressure of 75 mm Hg b) Crackles and shallow breathing c) Cold, clammy skin and tachycardia d) A heart rate of 140

c) Compensatory respiratory alkalosis Pg. 276 In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid. PaCO2 >45 mm Hg, is an expected finding in the progressive state of shock.

66. A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? a) Metabolic acidosis b) PaCO2 >45 mm Hg c) Compensatory respiratory alkalosis d) Heart rate <100 bpm

d) Using a central venous line Pg. 283 Vasoactive medications should be administered through a central venous line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV push.

67. How should vasoactive medications be administered? a) Intramuscularly (IM) b) By rapid intravenous (IV) push c) Through a peripheral IV line d) Using a central venous line

b) Restores blood pressure Pg. 275 The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone.

68. The nurse is caring for a client in the compensation stage of shock. One of the body's mechanisms of compensation in this stage of shock is the action of the renin-angiotensin-aldosterone system. What does this system do? a) Increases catecholamine secretion b) Restores blood pressure c) Increases the production of antidiuretic hormone d) Decreases peripheral blood flow

b) Neurogenic Pg. 296 Neurogenic shock results from an insult to the vasomotor center of the medulla or to the peripheral nerves that extend from the spinal cord to the blood vessels. The tone of the sympathetic nervous system is impaired, resulting in deceased arterial vascular resistance, vasodilation, and hypotension. Anaphylactic shock has vasodilation also as a key characteristic, along with increased capillary permeability, swelling of the airway, hives, and itching. Septic shock is associated with overwhelming bacterial infections. Obstructive shock is when there is an interference of blood flow in and out of the heart.

69. A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock? a) Anaphylactic b) Neurogenic c) Septic d) Obstructive

b) Tachycardia Pg. 276 The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

7. When a client is in the compensatory stage of shock, which symptom occurs? a) Bradycardia b) Tachycardia c) Respiratory acidosis d) Urine output of 45 mL/hr

d) Compensated respiratory alkalosis Pg. 276 In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The Pa CO2 would be increased in compensatory stage of shock. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid.

70. A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? a) Heart rate >20 bpm b) PaCO2 <32 mm Hg c) Metabolic acidosis d) Compensatory respiratory alkalosis

c) 8 to 12 mm Hg Pg. 282 The goal in colloidal fluid replacement is to achieve a central venous pressure of 8 to 12 mm Hg or higher (normal = 2 to 8 mm Hg).

71. The nurse is administering colloids to a client during the first 6 hours of septic shock. What is the client's central venous pressure reading goal? a) 1 to 3 mm Hg b) 4 to 5 mm Hg c) 8 to 12 mm Hg d) 6 to 7 mm Hg

c) Nitroprusside Pg. 285 A disadvantage of nitroprusside (Nipride) is that it causes hypotension. Dopamine (Intropin) improves contractility, increases stroke volume, and increases cardiac output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction.

72. In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? a) Epinephrine b) Methoxamine c) Nitroprusside d) Dopamine

b) Increase in arterial oxygenation Pg. 276 Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. Catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.

73. The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? a) Decreased white blood cell count b) Increase in arterial oxygenation c) Regulation of sodium and potassium d) Decreased depressive symptoms

a) Vital signs b) Urine output d) Peripheral pulses f) Skin color Pg. 280 Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation.

74. The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply. a) Vital signs b) Urine output c) Nutrition d) Peripheral pulses e) Gait f) Skin color

d) Parasympathetic Pg. 296 The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The client experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation.

75. Clinical characteristics of neurogenic shock are noted by which type of stimulation? a) Sympathetic b) Endocrine c) Cerebral d) Parasympathetic

d) Bradycardia Pg. 296 The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

76. Which of the following is a clinical characteristic of neurogenic shock? a) Moist skin b) Cool skin c) Tachycardia d) Bradycardia

a) H2 blockers c) Antacids e) Proton pump inhibitors Pg. 284 Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, H2 blockers [e.g., famotidine (Pepcid)], and proton pump inhibitors [e.g., lansoprazole (Prevacid), esomeprazole magnesium (Nexium)] are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Proteases and peptidases split proteins into small peptides and amino acids and help with digestion. A promotility agent such as metoclopramide is used to decrease nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite.

77. A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply. a) H2 blockers b) Promotility agents c) Antacids d) Proteases e) Proton pump inhibitors

b) Progressive Pg. 276 In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

78. When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? a) Compensatory b) Progressive c) Refractory d) Irreversible

a) A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume Pg. 274 Shock may have different causes (e.g., hypovolemic, cardiogenic, septic) but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Option B could reflect dependent edema and sepsis. Option C reflects hypovolemia. Option D is reflective of anaphylactic or distributive shock.

79. A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? a) A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume b) A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces c) Generally caused by decreased blood volume d) Due to severe hypersensitivity reaction resulting in massive systemic vasodilation

c) Aortic insufficiency Pg. 289 A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.

8. A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? a) Unstable angina pectoris b) Diabetes mellitus c) Aortic insufficiency d) Hypertension

c) 100% oxygen via a nonrebreather mask Pg. 282 The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied via a nonrebreather mask. The other orders should be completed after the client's airway is secure.

80. A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? a) Two large-bore IVs and begin crystalloid fluids b) C-spine x-rays c) 100% oxygen via a nonrebreather mask d) Type and cross match

b) Urinary output c) Vital signs e) Mental status Pg. 282 Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. The patient receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema.

81. When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) a) Ability to perform range of motion exercises b) Urinary output c) Vital signs d) Visual acuity e) Mental status

b) <180 mg/dL Pg. 280 Tight glycemic control (serum glucose of 80 to 100 mg/dL) is no longer recommended, as hypoglycemic events associated with regulating tight control in critically ill clients have been found to result in adverse patient outcomes. Current evidence suggests that maintaining serum glucose levels lower than 180 mg/dL with insulin therapy and close monitoring is indicated in the management of the critically ill client.

82. A nurse is performing glucose checks for a client in the progressive stage of shock. What glucose range would the nurse expect to see for the best outcome with the client? a) <200 mg/dL b) <180 mg/dL c) <60 mg/dL d) <80 mg/dL

a) Ondansetron Pg. 286 An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).

9. A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next? a) Ondansetron b) Loperamide c) Magnesium hydroxide d) Meperidine