Ch. 14: Shock & Multiple Organ Dysfunction Syndrome

In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart? Methoxamine Epinephrine Nitroprusside Dopamine

Correct response: Nitroprusside Explanation: A disadvantage of nitroprusside is that it causes hypotension. Dopamine and epinephrine improve contractility, increase stroke volume, and increase cardiac output. Methoxamine increases blood pressure by vasoconstriction.

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? Hemoglobin: 14.2 g/dL ESR: 19 mm/hour WBC: 42,000/mm3 Potassium: 4.8 mEq/L

Correct response: WBC: 42,000/mm3 Explanation: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

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? 60% 50% 70% 40%

Correct response: 70% Explanation: 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%.

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? Nitroprusside Epinephrine Dopamine Methoxamine

Correct response: Nitroprusside Explanation: 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.

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: Arrhythmias. Cardiomyopathies. Valvular damage. A myocardial infarction.

Correct response: A myocardial infarction. Explanation: Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

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. 90 mm Hg 70 mm Hg 60 mm Hg 80 mm Hg

Correct response: 60 mm Hg Explanation: Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? "Infuse I.V. fluids at 83 ml/hour." "Administer oxygen by nasal cannula at 3 L/minute." "Monitor urine output every hour." "Draw samples for hemoglobin and hematocrit every 6 hours."

Correct response: "Infuse I.V. fluids at 83 ml/hour." Explanation: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? "The client is in shock because the heart is unable to circulate the body fluids." "The client is in shock because your loved one is not responding and brain dead." "The client is in shock because all peripheral blood vessels have massively dilated." "The client is in shock because the blood volume has decreased in the system."

Correct response: "The client is in shock because the blood volume has decreased in the system." Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.

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? Type and cross match C-spine x-rays 100% oxygen via a nonrebreather mask Two large-bore IVs and begin crystalloid fluids

Correct response: 100% oxygen via a nonrebreather mask Explanation: 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.

The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour? 5.5 mL/hr 2.7 mL/hr 8.0 mL/hr 11 mL/hr.

Correct response: 2.7 mL/hr Explanation: The nurse should administer 2.7 mL/hr: 1 mcg/90 kg/60 minutes/2,000 (concentration)

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? Thready 24 Palpable Within normal limits

Correct response: 24 Explanation: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse.

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? A weak and thready pulse A slow and imperceptible pulse A slow but steady pulse A rapid, bounding pulse

Correct response: A rapid, bounding pulse Explanation: 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.

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 weak and thready pulse A slow and imperceptible pulse A slow but steady pulse A rapid, bounding pulse

Correct response: A rapid, bounding pulse Explanation: 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.

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? Begin a continuous IV infusion of insulin per protocol. Initiate enteral feedings as prescribed. Administer recombinant human activated protein C (rhAPC) as prescribed. Administer norepinephrine as prescribed.

Correct response: Administer norepinephrine as prescribed. Explanation: 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.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next Calls the Rapid Response Team Contacts the admitting physician Administers oxygen by nasal cannula at 2 liters per minute Re-assesses the vital signs

Correct response: Administers oxygen by nasal cannula at 2 liters per minute Explanation: The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? Hormone antagonist drugs Antimetabolite drugs Adrenergic drugs Anticholinergic drugs

Correct response: Adrenergic drugs Explanation: Adrenergic drugs are the main medications used to treat shock.

Which colloid is expensive but rapidly expands plasma volume? Albumin Dextran Lactated Ringer solution Hypertonic saline

Correct response: Albumin Explanation: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage? Lactated Ringer solution Albumin Hypertonic saline Dextran

Correct response: Albumin Explanation: Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared with crystalloid solutions. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

Which type of shock occurs from an antigen-antibody response? Neurogenic Anaphylactic Cardiogenic Septic

Correct response: Anaphylactic Explanation: 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.

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? Hypertension Aortic insufficiency Unstable angina pectoris Diabetes mellitus

Correct response: Aortic insufficiency Explanation: 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.

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

Correct response: Narrowed pulse pressure Explanation: 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.

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. Administer vasoconstrictive medications to clients at risk for shock. Administer prophylactic packed red blood cells to clients at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs. Assess the client who is at risk for shock.

Correct response: Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs. Explanation: 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.

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: Breath sounds. Heart rate. Blood pressure. Renal output.

Correct response: Blood pressure. Explanation: 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.

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? Kidneys Lungs Brain Liver

Correct response: Brain Explanation: 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.

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? Circulatory (distributive) Hypovolemic Obstructive Carcinogenic

Correct response: Circulatory (distributive) Explanation: Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcatagories.

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock? Hypovolemic Obstructive Cardiogenic Circulatory (distributive)

Correct response: Circulatory (distributive) Explanation: Vasodilatation, a prominent characteristic of circulatory/distributive shock, increases the space in the vascular bed. Central blood flow is reduced because peripheral vascular or interstitial areas exceed their usual capacity. Vasodilation is not a major component of cardiogenic, hypovolemic, or obstructive shock.

At what point in shock does metabolic acidosis occur? Compensation Irreversible Early Decompensation (Progressive)

Correct response: Decompensation (Progressive) Explanation: 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. Therefore, options A, B, and C are incorrect.

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 Salt-poor albumin Hetastarch Packed red blood cells Dextran

Correct response: Dextran Explanation: 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.

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? Obstructive Carcinogenic Hypovolemic Distributive

Correct response: Distributive Explanation: 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.

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 Encourage the family to touch and talk to the client. Inform the family that everything is being done to assist with the client's survival. Open up discussion among the family members about nursing home placement. Contact a spiritual advisor to provide comfort to the family.

Correct response: Encourage the family to touch and talk to the client. Explanation: 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.

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm? Proventil Benadryl Prednisone Epinephrine

Correct response: Epinephrine Explanation: Epinephrine is given for its vasoconstrictive actions, as well as for its rapid effect of reducing bronchospasm. Benadryl and Proventil (nebulized) are given to reverse the effects of histamine. Prednisone is given to reduce inflammation, if necessary.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? Head injury Myocardial infarction Multiple sclerosis Diabetes

Correct response: Head injury Explanation: 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.

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply. Obstructive shock; kidney stone Neurogenic shock; diabetes Hypovolemic shock; blood loss Anaphylactic shock; nuts Cardiogenic shock; myocardial infarction Septic shock; infection

Correct response: Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nuts Septic shock; infection Explanation: 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.

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

Correct response: Increase the force of myocardial contraction Explanation: 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.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. Decreases in liver enzymes Reports of chest pain Loss in consciousness Ecchymoses and petechiae Increased paCO² levels

Correct response: Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae Explanation: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activites of the liver are impaired, and liver enzymes will increase.

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? Pericardiocentesis Administration of oxygen via venture mask Intubation and mechanical ventilation Thoracotomy with chest tube insertion

Correct response: Intubation and mechanical ventilation Explanation: Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Periocardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? Irreversible Precompensatory Compensatory Progressive

Correct response: Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

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? 0.9% sodium chloride Albumin Dextran Lactated Ringer's

Correct response: Lactated Ringer's Explanation: Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? Unable to measure Low Normal High

Correct response: Low Explanation: The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.

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 Lung sounds Mental status Bowel sounds Skin perfusion

Correct response: Lung sounds Explanation: 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.

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

Correct response: Maintain activity restriction to bedrest. Explanation: 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.

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? ScvO2 of 60% Urine output of 0.2 mL/kg/hr Mean arterial pressure of 70 mm Hg Central venous pressure of 6 mm Hg

Correct response: Mean arterial pressure of 70 mm Hg Explanation: 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%.

Which positioning strategy should be used for the client diagnosed with hypovolemic shock? Supine Modified Trendelenburg Prone Semi-Fowler's

Correct response: Modified Trendelenburg Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

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: Morphine 2 mg intravenously Oxygen at 2 L/min by nasal cannula Dopamine (Intropin) intravenous solution NS at 60 mL/hr via an intravenous line

Correct response: Oxygen at 2 L/min by nasal cannula Explanation: 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.

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? Compensatory Progressive Irreversible Refractory

Correct response: Progressive Explanation: 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.

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? Compensatory Refractory Progressive Irreversible

Correct response: Progressive Explanation: 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.

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

Correct response: Restores blood pressure Explanation: The renin-angiotensin-aldosterone systemis 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.

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? Anaphylactic Septic Neurogenic Cardiogenic

Correct response: Septic Explanation: 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.

Which type of shock is caused by an infection? Septic Anaphylactic Hypovolemic Cardiogenic

Correct response: Septic Explanation: Septic shock is caused by an infection. Cardiogenic shock occurs when the heart has an impaired pumping ability. Hypovolemic shock occurs when ththe intravascular volume has decreased. Anaphylactic shock is caused by a hypersensitivity reaction.

The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately? The client's heart rate is greater than 90 beats per minute. The client's respiratory rate is less than 20 breaths per minute. The client feels restless and hungry. The client exhibits an increased urinary output.

Correct response: The client's heart rate is greater than 90 beats per minute. Explanation: A heart rate greater than 90 beats per minute or a respiratory rate greater than 20 breaths per minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.

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

Correct response: The difference between the systolic and diastolic pressure Explanation: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.

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: Vesicular breath sounds are audible in the lung periphery. Bilateral pedal pulses are 1+. The right foot is cooler than the left foot. The balloon deflates prior to systole.

Correct response: The right foot is cooler than the left foot. Explanation: 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.

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

Correct response: Use strict hand hygiene techniques. Explanation: 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.

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? compensatory respiratory alkalosis heart rate >20 bpm metabolic acidosis PaCO2 <32 mm Hg

Correct response: compensatory respiratory alkalosis Explanation: In the compnesatory 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.

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? irreversible stage compensation stage cardiogenic shock decompensation stage

Correct response: decompensation stage Explanation: 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.

What is the major clinical use of dobutamine? treat hypotension. prevent sinus bradycardia. increase cardiac output. treat hypertension.

Correct response: increase cardiac output. Explanation: 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.

A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing? neurogenic cardiogenic anaphylactic hypovolemic

Correct response: neurogenic Explanation: Neurogenic shock can be caused by spinal cord injury, spinal anesthesia, or other nervous system damage; client symptoms include dry skin and bradycardia with hypotension. Cardiogenic shock is seen in clients with impaired heart function. Hypovolemic shock is caused by decreased intravascular volume. Anaphylactic shock is caused by a severe allergic reaction; clients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen-antibody reaction; specifically, an immunoglobulin E-mediated response.

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? anaphylactic shock septic shock neurogenic shock hypovolemic shock

Correct response: neurogenic shock Explanation: 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.

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 mediciations would the nurse administer next? loperamide ondansetron meperidine magnesium hydroxide

Correct response: ondansetron Explanation: 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]).

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? organ damage unsteady gait liver dysfunction weight loss

Correct response: organ damage Explanation: 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.