Chapter 34

The student nurse is explaining body responses to alterations of fluid balance. Which statement made by the student requires correction? 1 "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." 2 "The hypothalamus contains osmoreceptors sensitive to changes in blood osmolarity." 3 "Antidiuretic hormone (ADH) is released from the posterior pituitary gland in response to changes in blood osmolarity." 4 "Aldosterone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid are low."

"Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." The student nurse requires correction when stating, "NPs are secreted by the kidneys to restore tissue perfusion." NPs are hormones secreted by special cells that line the atria of the heart in response to increased blood volume and blood pressure. The other statements are correct. The hypothalamus contains osmoreceptors that are sensitive to changes in blood osmolarity. Aldosterone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid are low. ADH is released from the posterior pituitary gland in response to changes in blood osmolarity.

The nurse is providing care to a female patient who experienced an adverse reaction to a prescribed drug. The patient states, "My husband was on the same dose, and he didn't have any issues." Which response would the nurse make? 1 "You are probably allergic to the prescribed drug." 2 "Women have less total body water, which causes differences in drug responses." 3 "There is no reason as to why certain people experience reactions to drugs." 4 "Men have less muscle mass, which why your husband didn't have the same reaction."

"Women have less total body water, which causes differences in drug responses." Women tend to have more fat cells, which means they have less total body water. This difference in water distribution explains why men and women have different responses to drugs. Not all adverse reactions indicate a drug allergy. There is evidence that suggests that the muscle versus fat composition of the body does impact individual reaction to drugs. Men have more muscle mass, not less muscle mass, within the body.

A patient diagnosed with dehydration asks, "Why is my urine so dark?" Which response would the nurse provide? 1 "Your kidneys are concentrating your urine to maintain fluid balance." 2 "It is likely that you have a urinary tract infection." 3 "One of your medications may be causing the dark color." 4 "Your urine is dilute because of the IV fluids you are receiving."

"Your kidneys are concentrating your urine to maintain fluid balance." In response to dehydration, the kidneys will concentrate the urine to decrease further fluid loss. The dark color of the urine is not due to a medication or a urinary tract infection. The urine is not dilute because of the IV fluids.

Which metabolic change occurs as a result of tissue ischemia during the compensatory stage of hypovolemic shock? Select all that apply. One, some, or all responses may be correct. 1 Acidosis 2 Alkalosis 3 Hypokalemia 4 Hyperkalemia 5 Vasodilatation

1 Acidosis 4 Hyperkalemia In the compensatory stage of shock, tissue hypoxia leads to acidosis because of changes in anaerobic metabolism. Hyperkalemia (not hypokalemia) occurs as well from the changes in metabolism. The patient is acidotic, not alkalotic. Hypovolemic shock is associated with vasoconstriction, not vasodilation.

The nurse enters the room of an older patient with a urinary tract infection who has developed septic shock. Which cue would the nurse expect to notice during the assessment to support this diagnosis? Select all that apply. One, some, or all responses may be correct. 1 Febrile 2 Agitation 3 Tachypnea 4 Tachycardia 5 Hypotension

1 Febrile 2 Agitation 3 Tachypnea 4 Tachycardia 5 Hypotension Clinical manifestations of septic shock include fever, changes in level of consciousness or new agitation, tachypnea, tachycardia, and systolic hypotension.

Which action would the nurse take to decrease a patient's risk for shock? Select all that apply. One, some, or all responses may be correct. 1 Give antibiotics. 2 Administer oxygen. 3 Initiate inotropic drugs. 4 Monitor blood pressure. 5 Obtain serum lactate level.

1 Give antibiotics. 2 Administer oxygen. 3 Initiate inotropic drugs. 4 Monitor blood pressure. 5 Obtain serum lactate level. The nurse should administer antibiotics to fight infection. Oxygen should be given to improve gas exchange. Inotropic drugs increase the contractility of the heart. Blood pressure should be monitored as a decrease is an early sign of septic shock. An increasing serum lactate level would indicate presence of sepsis.

The nurse is planning care for a patient receiving phenylephrine to treat hypovolemic shock. Which parameter would the nurse assess to prevent complications? Select all that apply. One, some, or all responses may be correct. 1 Headaches 2 Hourly urine output 3 Presence of chest pain 4 IV site every 30 minutes 5 Blood pressure every 15 minutes

1 Headaches 2 Hourly urine output 3 Presence of chest pain 4 IV site every 30 minutes 5 Blood pressure every 15 minutes The nurse would assess the patient for headaches as they can be a sign of drug toxicity. Hourly urine output would be monitored as the medication can decrease urinary output because of its effect on kidney perfusion. Chest pain is a sign of myocardial vasoconstriction, so the nurse would assess for this adverse effect. The nurse will monitor the IV site for extravasation as this medication can cause tissue necrosis if it leaks into the surrounding tissues. The nurse should check the blood pressure every 15 minutes for signs of drug excess.

Which condition is a risk factor for hypovolemic shock? Select all that apply. One, some, or all responses may be correct. 1 Hemophilia 2 Dehydration 3 Diuretic therapy 4 Spinal cord injury 5 Myocardial infarction

1 Hemophilia 2 Dehydration 3 Diuretic therapy

The nurse identifies a patient admitted with an upper GI bleed is at an increased risk for hypovolemic shock. Which action would the nurse take to decrease this risk? Select all that apply. One, some, or all responses may be correct. 1 Observe vital signs. 2 Assess urinary output. 3 Palpate peripheral pulses. 4 Monitor level of consciousness. 5 Check skin color and temperature.

1 Observe vital signs. 2 Assess urinary output. 3 Palpate peripheral pulses. 4 Monitor level of consciousness. 5 Check skin color and temperature. Clinical manifestations found in the initial stage of hypovolemic shock include decreased systolic and increased diastolic blood pressure and decreased urinary output. The nurse would palpate peripheral pulses as their strength diminishes with hypovolemic shock. The patient in the progressive stage of shock would show changes in their mental status. The nurse would assess skin color and temperature. The patient would become cold and clammy because of decreased peripheral circulation.

Which symptom occurs in the compensatory phase of shock? Select all that apply. One, some, or all responses may be correct. 1 Restlessness 2 Decreased urine output 3 Decreased tissue perfusion 4 Increased respiratory rate 5 Widening pulse pressure

1 Restlessness 2 Decreased urine output 3 Decreased tissue perfusion 4 Increased respiratory rate Signs and symptoms of the compensatory stage of shock include changes resulting from decreased tissue perfusion. Objective changes include restlessness, tachycardia, increased respiratory rate, decreased urine output, falling systolic blood pressure, rising diastolic blood pressure, narrowing (not widening) pulse pressure, cool extremities, and a decrease in oxygen saturation.

Which assessment findings are consistent with the nonprogressive (compensatory) phase of shock? Select all that apply. 1 Cool skin 2 Bradycardia 3 Elevated liver function tests 4 Restlessness 5 Tachypnea 6 Anxiety

1,4,5,6 Thirst, anxiety, restlessness, tachycardia, and increased respiratory rate (tachypnea) along with oliguria and narrowing pulse pressure appear in the nonprogressive (compensatory) stage of shock. Organ damage manifested by increased liver enzymes or kidney function occur in the progressive or intermediate phase of shock. Tachycardia, rather than bradycardia, occurs in shock states secondary to catecholamines released as compensatory mechanisms.

Which factor would affect the mean arterial pressure (MAP), which decreases perfusion? Select all that apply. One, some, or all responses may be correct. 1 Oxygenation 2 Blood viscosity 3 Cardiac output 4 Total blood volume 5 Size of vascular bed

2 Blood viscosity 3 Cardiac output 4 Total blood volume 5 Size of vascular bed The MAP is affected by the viscosity of the blood, the amount of blood pumped by the heart (cardiac output), the total blood volume, and the size of the vascular bed. Oxygenation affects perfusion but not the MAP.

Which sign or symptom occurs in the compensatory stage of shock? Select all that apply. One, some, or all responses may be correct. 1 Cyanosis 2 Restlessness 3 Increased respiratory rate 4 Decreased urine output 5 Tachycardia

2 Restlessness 3 Increased respiratory rate 4 Decreased urine output 5 Tachycardia Signs and symptoms of the compensatory stage of shock include changes resulting from decreased tissue perfusion. Objective changes include restlessness, increased respiratory rate, decreased urine output, and tachycardia. Cyanosis appears later, in the progressive stage of hypovolemic shock.

Which point would the nurse consider during the psychosocial assessment of a patient who is suspected to have hypovolemia? Select all that apply. One, some, or all responses may be correct. 1 Questions should not be repeated. 2 The patient should respond to the question asked. 3 The nurse should check if the patient becomes irritated or upset. 4 Questions should be phrased in a "yes" or "no" format. 5 The nurse should determine if the patient is able to concentrate on a question for long.

2 The patient should respond to the question asked. 3 The nurse should check if the patient becomes irritated or upset.5 The nurse should determine if the patient is able to concentrate on a question for long. The nurse should assess whether the response of a patient with suspected hypovolemia answers the question asked. It is also important to check if the patient becomes irritated or upset when questions are asked again and again. If the patient gets upset or irritated, it shows that the patient is not able to handle mental stress. The patient's concentration level is important in determining if the patient has a limited attention span. Questions should be repeated so that the patient can understand the question completely and give a correct response. In psychometric assessment, the questions should not be phrased in a "yes" or "no" format because the mental level of the patient cannot be judged when only required to give one-word answers.

Which hormone is responsible for maintaining fluid balance? Select all that apply. One, some, or all responses may be correct. 1 Insulin 2 Glucagon 3 Aldosterone 4 Natriuretic peptide (NP) 5 Antidiuretic hormone (ADH)

3 Aldosterone 4 Natriuretic peptide (NP) 5 Antidiuretic hormone (ADH) Aldosterone, NP, and ADH are the three hormones that are responsible for maintaining fluid balance within the body. Insulin and glucagon are responsible for maintaining blood glucose levels in the body, not fluid balance.

Which clinical manifestation of septic shock distinguishes it from hypovolemic shock? Select all that apply. One, some, or all responses may be correct. 1 Increased lactic acid level 2 Increased potassium level 3 Decreased blood pressure 4 Increased blood glucose level 5 Decreased mean arterial pressure

3 Decreased blood pressure 4 Increased blood glucose level In sepsis, the blood pressure reduces, and stress causes a continuous release of glucose from the liver, which leads to hyperglycemia. In hypovolemic shock, the blood pressure increases, and the glucose level may not be affected. Increased lactic acid level, potassium level, and a decreased mean arterial pressure are manifestations of both septic shock and hypovolemic shock.

Which laboratory value would the nurse expect to be decreased when reviewing the laboratory results for a patient with hypovolemic shock because of blood loss? Select all that apply. One, some, or all responses may be correct. 1 Sodium 2 Potassium 3 Lactic acid 4 Hematocrit 5 Hemoglobin

4 Hematocrit 5 Hemoglobin A patient with hypovolemic shock because of blood loss would present with a decreased hemoglobin and hematocrit. Potassium and sodium would be increased with hypovolemic shock, not decreased. Lactic acid also would be increased with hypovolemic shock.

For which reason would a patient who was given treatment for sepsis and discharged from the hospital present again a few days later with severe sepsis? 1 Increased physical activity 2 Excessive consumption of liquids 3 A delay in the disease progression 4 Oversleep during the treatment regimen

A delay in the disease progression The symptoms associated with sepsis show lots of variations as the disease develops. Most of the physiologic changes fluctuate in severe sepsis; therefore many patients are discharged from the hospital quicker and sicker than they should be. Increased physical activity does not trigger the symptoms of sepsis. Excessive consumption of liquids does not increase sepsis in patients. Oversleep may make the patient dull but does not increase the risk for sepsis in the patient.

Which type of medication may affect the assessment of a patient's fluid balance? 1 Anticoagulant once daily 2 Cardiac glycoside once daily 3 Antibiotic every 6 hours 4 Angiotensin-converting enzyme (ACE) inhibitor twice daily

Angiotensin-converting enzyme (ACE) inhibitor twice daily Urine output is used as an indicator of perfusion adequacy after surgery or other procedures. Medications used to manage hypertension such ACE inhibitors disrupt the renin-angiotensin II pathway, resulting in greater excretion of water and sodium in the urine. This may make it harder to use urine output as a primary measure of perfusion. Anticoagulants prolong clotting. Antibiotics and cardiac glycosides will not affect monitoring fluid balance.

In which location are the baroreceptors found? 1 Aortic arch 2 Radial sinus 3 Brachial arch 4 Femoral sinus

Aortic arch The baroreceptors responsible for detecting pressure changes in the arterial system are located in the aortic arch and carotid sinus. There are no baroreceptors located in the radial sinus, brachial arch, or femoral sinus.

Which assessment factor is used to verify the effectiveness of norepinephrine to treat hypovolemic shock? 1 Blood pressure 2 Urinary output 3 Level of consciousness 4 Blood glucose

Blood pressure Norepinephrine is a vasoconstrictor drug used in hypovolemic shock to increase perfusion and oxygenation. These drugs constrict the blood vessels and increase venous return. Urine production will not increase until blood pressure rises and perfuses the kidneys. Norepinephrine does not have any effect on a patient's level of consciousness or blood glucose levels.

Which action will the nurse take for a postoperative patient with a blood pressure (BP) of 90/60 mm Hg, a heart rate of 80 beats/min, and a respiratory rate of 22 breaths/min? 1 Compare these vital signs with the last several readings. 2 Request the surgeon see the patient. 3 Increase the rate of IV fluids. 4 Reassess vital signs using different equipment.

Compare these vital signs with the last several readings. Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may be normal for this patient. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment should be used when vital signs are taken postoperatively.

Which stage of hypovolemic shock is indicated by a pulse oximetry value of 93%? 1 Initial 2 Refractory 3 Progressive 4 Compensatory

Compensatory In the compensatory stage of hypovolemic shock, the pulse oximetry value ranges from 90% to 95%. If the value is above 95%, it indicates the initial stage of hypovolemic shock. Any value below 70% indicates the refractory stage. In the progressive stage, the value lies between 75% and 80%.

Which clinical manifestation may be associated with septic shock? 1 Cool skin 2 Urine output of 30 mL/hr 3 Lactic acid level of 5 mg/dL 4 Mean arterial pressure of 90 mm Hg

Cool skin In septic shock, the skin becomes cold when the cardiac output decreases below the normal level. The urine output of 30 mL/hr indicates normal conditions. A lactic acid level of 5 mg/dL is normal because the normal level of lactic acid lies between 3 and 7 mg/dL. A mean arterial pressure of 90 mm Hg indicates normal functioning of the body organs.

Which assessment finding would the nurse report to the health care provider as a possible indicator of compensatory stage of shock for a patient admitted with a bleeding duodenal ulcer who is NPO status and has a nasogastric tube in place connected to low continuous suction? 1 Serum potassium level of 4.7 mEq/L 2 Decrease in mean arterial pressure (MAP) from 76 mm Hg to 62 mm Hg 3 Urine output of 30 mL/hr 4 Increased confusion

Decrease in mean arterial pressure (MAP) from 76 mm Hg to 62 mm Hg When shock progresses from the initial stage to the nonprogressive stage, symptoms are subtle but present. Once the patient enters the progressive and refractory stage of shock, manifestations are more obvious and may not be responsive to therapy. Recognizing early manifestations of shock are important to patient outcomes. The nonprogressive stage of shock is present when the MAP decreases by 10 to 15 mm Hg from baseline, urine output decreases, and heart rate and respiratory rate increase. Confusion and moderate hyperkalemia is observed in the progressive stage of shock. The patient's urine output is still within normal limits as may be seen in the initial stage of shock, but urine output will continue to decrease as the shock stages progress.

Which laboratory result is seen in late sepsis? 1 Decreased serum lactate 2 Decreased segmented neutrophil count 3 Increased numbers of monocytes 4 Increased platelet count

Decreased segmented neutrophil count A decreased segmented neutrophil count is indicative of late sepsis. Serum lactate is increased in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis; late in sepsis, platelets may decrease because of consumptive coagulopathy.

Which change common in older adults has a neurologic cause? 1 Decreased thirst reflex 2 Increased urine output 3 Increased muscle mass 4 Decreased sweat production

Decreased thirst reflex An age-related neurologic change that impacts fluid balance is a decreased thirst reflex. Urine output, muscle mass, and sweat production may all impact fluid balance, but these are not age-related neurologic changes.

Which condition is associated with hypovolemic shock? 1 Dehydration 2 Pulmonary embolus 3 Myocardial infarction 4 Chemical-induced sepsis

Dehydration Dehydration is a symptom of hypovolemic shock. This is because in hypovolemic shock there is a decrease in the total body fluids. Pulmonary embolus is a result of direct pump failure, which indicates cardiogenic shock. Myocardial infarction occurs because of decreased cardiac function, which causes obstructive shock. Chemical-induced sepsis is caused by fluid shift from the central vascular space. This results in distributive shock.

Which condition is a risk factor for distributive shock? 1 Use of Ginkgo biloba 2 Diminished thirst reflex 3 Diminished immune response 4 Presence of cardiomyopathies

Diminished immune response Diminished immune response is a risk factor for distributive shock, including sepsis and septic shock. Use of Ginkgo biloba can result in hypovolemic shock. Diminished thirst reflex is a risk factor for hypovolemic shock. Presence of cardiomyopathies is a risk factor for cardiogenic shock.

Which abnormality would the nurse expect to see when reviewing the arterial blood gas results for a patient with hypovolemic shock? 1 Increased pH 2 Increased partial pressure of arterial oxygen (Pao2) 3 Decreased partial pressure of arterial carbon dioxide (Paco2) 4 Elevated lactic acid

Elevated lactic acid The nurse would expect to find an elevated lactic acid level in a patient with hypovolemic shock. Other findings would include a decreased pH and Pao2 and an increased Paco2.

Which physiologic change is related to septic shock? 1 High blood pressure 2 Elevated white blood cell (WBC) count 3 Increased urinary output 4 Decreased respiratory rate

Elevated white blood cell (WBC) count Septic shock is always due to an underlying infection. An elevated WBC count is associated with septic shock. There is a progressive organ dysfunction resulting in low blood pressure and decreased urinary output. The respiratory rate is increased to compensate for hypoxia in the tissues.

A patient in the progressive stage of hypovolemic shock will exhibit which manifestation? 1 Polyuria 2 Metabolic alkalosis 3 Moist, warm skin 4 Feeling of impending doom

Feeling of impending doom As shock progresses, tissue perfusion to the brain continues to be reduced, causing a sense of anxiety or that "something bad" is about to happen. Oliguria or anuria occurs in the compensatory stage rather than polyuria. Because of decreased tissue perfusion, buildup of lactic or metabolic acid occurs; the arterial blood gases reflect metabolic acidosis at this time. A lack of perfusion to the skin results in cool, moist skin rather than warm skin.

A patient with which condition has an increased risk for hypovolemic shock? 1 GI ulcer 2 Kidney failure 3 Arthritis and daily acetaminophen use 4 Kidney stone

GI ulcer GI ulcers may hemorrhage, causing massive GI bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. NSAIDs such as naproxen and ibuprofen, not acetaminophen, predispose the patient to GI bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss and hypovolemia.

The nurse is planning care for a patient with dehydration to minimize complications. Which action would the nurse take to prevent hypovolemic shock? 1 Administer oxygen. 2 Insert a urinary catheter. 3 Give IV fluids. 4 Assess peripheral pulses.

Give IV fluids. The nurse would implement interventions that would maintain adequate fluid volume. Therefore the nurse would encourage oral fluid intake and give IV fluids. The nurse would administer oxygen to improve oxygen levels, a urinary catheter would be inserted to measure intake and output, and peripheral pulses would be assessed to monitor perfusion, but these do not prevent hypovolemic shock.

Which condition may be associated with a hematocrit level of 29%? 1 Normal perfusion 2 Edema 3 Dehydration 4 Hemorrhage

Hemorrhage In hemorrhage, the hematocrit value decreases from the normal adult level of 42% to 52% for men and 37% to 47% for women. Edema results from fluid shift, which causes hematocrit levels to increase. Dehydration also results in an elevated hematocrit value.

hich drug may be used to treat adrenal insufficiency for a patient with sepsis and septic shock? 1 Insulin 2 Heparin 3 Dobutamine 4 Hydrocortisone

Hydrocortisone Low-dose corticosteroids may be given during the treatment of adrenal insufficiency in patients with sepsis and septic shock. Hydrocortisone may be given IV for treatment of these patients. Insulin may be given to control blood glucose levels. Heparin may be given to patients with sepsis and septic shock to manage microvascular abnormalities. Dobutamine is an inotropic agent used for treating hypovolemic shock. It helps to manage hypotension.

Which drug is prescribed to patients with septic shock but not with hypovolemic shock? 1 Milrinone 2 Hydrocortisone 3 Sodium nitroprusside 4 Phenylephrine hydrochloride (HCl)

Hydrocortisone Severe sepsis may result in adrenal insufficiency. Therefore low doses of corticosteroids are prescribed in the form of IV hydrocortisone during the treatment to prevent adrenal insufficiency. In hypovolemic shock, adrenal insufficiency may not occur. Milrinone helps in improving contractility, and its administration is not limited to septic shock. Sodium nitroprusside improves myocardial perfusion and is not limited to septic shock. Phenylephrine HCl helps in improving mean arterial pressure and therefore can be prescribed in patients with sepsis and hypovolemia.

Which type of shock may result if hemorrhage in a patient is not treated in time? 1 Distributive 2 Obstructive 3 Cardiogenic 4 Hypovolemic

Hypovolemic Hemorrhage can result in hypovolemic shock, which occurs when the mean arterial pressure decreases because of loss of blood from the vascular space, resulting in inadequate total body perfusion and oxygenation. A loss of blood does not result in distributive, obstructive, and cardiogenic shock; therefore these are not associated with hemorrhage.

Which physiologic change is seen in a patient with prolonged sepsis? Select all that apply. One, some, or all responses may be correct. 1 Hypoxia 2 Increase in white blood cell (WBC) levels 3 Increase in platelet count 4 Decrease in urine output 5 Change in patient cognition

Hypoxia Decrease in urine output Change in patient cognition Because of a decrease in cell uptake of oxygen in patients with severe sepsis, the cell has a low oxygen supply, a condition known as hypoxia. The patient also has decreased or no urine output because of organ dysfunction caused by severe sepsis. In more severe conditions, there is a change in the patient's cognition because of impaired immune response. Prolonged sepsis may have exceeded the bone marrow's ability to produce and release new mature neutrophils and other WBCs. Therefore the WBC count is extremely low in this case. The platelet count also decreases because the platelets and clotting factors were consumed in an earlier stage of sepsis.

The nurse is caring for a patient in the beginning stages of sepsis. Which factor would affect gas exchange and tissue perfusion at this time? Select all that apply. One, some, or all responses may be correct. 1 Tachypnea 2 Inflammation 3 Oxidative stress 4 Vascular changes 5 Decreased urine output

Inflammation 3 Oxidative stress 4 Vascular changes As the bacteria multiply and spread throughout the body, this activates the inflammatory process, which causes oxidative stress and vascular changes. Tachypnea and decreased urinary output are the end result of impaired gas exchange and tissue perfusion.

Which aspect of the patient's history is a likely cause of hyperkalemia? 1 Cirrhosis 2 Kidney failure 3 Heart failure 4 Hyperaldosteronism

Kidney failure Kidney disease, such as renal failure, causes a decrease in urine output, causing the patient to retain potassium and develop hyperkalemia. Cirrhosis is associated with hyponatremia, not hyperkalemia. Heart failure causes fluid overload. Hyperaldosteronism causes an increase in urine output, which causes hypokalemia, not hyperkalemia.

Which physiologic change in a patient with septic shock indicates a poor prognosis? 1 Rapid respiratory rate 2 Low oxygen saturation 3 Change in patient's cognition 4 Lactate level of 4.4 mmol/L

Lactate level of 4.4 mmol/L Lactate levels of 4 mmol/L or higher are associated with a 30% mortality rate. A rapid respiratory rate, low oxygen saturation, and a change in the patient's cognition are present during this stage of severe sepsis; however, these can be reversed with appropriate and timely treatment.

Which issue would the nurse anticipate finding in a patient with septic shock who has disseminated intravascular coagulation (DIC)? 1 Polycythemia 2 Thrombocytosis 3 Elevated serum bicarbonate levels 4 Low fibrinogen levels

Low fibrinogen levels Late in septic shock, hematocrit and hemoglobin levels, fibrinogen levels, and platelet count are low from DIC. A reduction in red blood cells, hemoglobin, and hematocrit, rather than an increase (polycythemia), occur in DIC. Thrombocytopenia (a reduction of platelets) rather than thrombocytosis (an increased number of platelets) occurs as these components are incorporated into the multiple small clots that develop in DIC. The serum lactate level is above normal, and the serum bicarbonate levels are lower than normal.

Which clinical symptoms in a postoperative patient indicate early sepsis with an excellent recovery rate if treated? 1 Localized erythema and edema 2 Low-grade fever and mild hypotension 3 Low oxygen saturation rate and decreased cognition 4 Reduced urinary output and an increased respiratory rate

Low-grade fever and mild hypotension Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and an increased respiratory rate indicate severe sepsis.

Which intervention is the priority for a 49-year-old patient who had a car accident and is admitted to the emergency department? 1 Administer oxygen. 2 Maintain a patent airway. 3 Examine for overt bleeding. 4 Maintain an established catheter.

Maintain a patent airway. A patient who had a car accident is at risk for hypovolemic shock. Maintaining a patent airway is the priority intervention for this patient because airway obstruction for a few minutes can lead to death. Administering oxygen helps minimize dyspnea after maintaining the airway. After maintaining the airway, the patient should be examined for overt bleeding, and if bleeding is observed, the nurse should apply direct pressure on the site to reduce the loss of blood. An established catheter should be maintained for IV fluid delivery after a patent airway is maintained.

A patient whose laboratory report shows decreased mean arterial pressure of 14 mm Hg from the patient's normal baseline may experience which effect on metabolism? 1 Mild acidosis 2 Hypoxia of vital organs 3 Multiple organ dysfunctions 4 Buildup of toxic metabolites

Mild acidosis The decrease in mean arterial pressure of 14 mm Hg from a normal baseline indicates the compensatory stage of hypovolemic shock. In this stage, there is a decrease in the mean arterial pressure of 10 to 15 mm Hg from the normal baseline. In this stage, a slight acid-base imbalance is present, which results in mild acidosis. In the progressive stage, the mean arterial pressure further decreases. This leads to hypoxia of the vital organs. The acid-base imbalance also increases, leading to moderate hyperkalemia. Any further increase in the mean arterial pressure leads to the refractory stage, which involves severe tissue hypoxia with ischemia and necrosis. This in turn, leads to multiple organ dysfunctions, which is also caused by a buildup of toxic metabolites.

The nurse is teaching a patient with congestive heart failure about monitoring fluid volume at home. Which patient action would provide the best indicator of fluid losses or gains? 1 Monitoring daily weights 2 Observing ankles for swelling 3 Monitoring daily intake and output 4 Observing for pulse elevations with activity

Monitoring daily weights Changes in daily body weight are the best indicators of fluid losses or gains. Swelling of the ankles may occur from being in a dependent position or standing for extended periods of time and is not necessarily due to alterations in fluid volume. Monitoring intake and output may be useful, but it is not as accurate as daily weights. The pulse normally rises with activities and decreases with rest. As such, observing the pulse with activity is not a good indicator of fluid status.

Which assessment finding is a cardiovascular manifestation of hypovolemic shock? Select all that apply. One, some, or all responses may be correct. 1 Narrow pulse pressure 2 Postural hypotension 3 Decreased pulse rate 4 Decreased cardiac output 5 Bounding peripheral pulses

Narrow pulse pressure Postural hypotension Decreased cardiac output In hypovolemic shock, total body fluid is reduced; therefore the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also, causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.In hypovolemic shock, total body fluid is reduced; therefore the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also, causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.

Which assessment finding is associated with the compensatory phase of hypovolemic shock? 1 Rise in systolic blood pressure 2 Narrowing pulse pressure 3 Slow, bounding pulse 4 +3 pedal pulses

Narrowing pulse pressure The compensatory stage of shock causes tachycardia, decreased systolic blood pressure, and increased diastolic blood pressure, which narrows the pulse pressure (difference between the systolic and diastolic pressures) secondary to catecholamine release. Typically, distal pulses are weak and thready as hypovolemic shock progresses.

The nurse is caring for a patient with hypovolemic shock because of a myocardial infarction. Which medication would the nurse expect the health care provider (HCP) to prescribe to improve myocardial perfusion? 1 Milrinone 2 Dobutamine 3 Nitroglycerine 4 Norepinephrine

Nitroglycerine The nurse would expect the HCP to prescribe nitroglycerine to improve myocardial perfusion as this drug causes vasodilation. Milrinone and dobutamine are inotropic drugs that improve cardiac contractility. Norepinephrine increases mean arterial pressure.

Which finding may reflect increased cardiac output in patients with septic shock? 1 Bradycardia 2 Decreased stroke volume 3 Normal central venous pressure (CVP) 4 Increase in systolic blood pressure

Normal central venous pressure (CVP) Increased cardiac output is reflected by a normal CVP. Increased cardiac output is reflected by tachycardia rather than bradycardia. Increased stroke volume and a normal systolic blood pressure may also reflect increased cardiac output.

Which action will the nurse take immediately for a patient who is admitted with new-onset hypotension, tachycardia, tachypnea, and elevated white blood cell count but whose blood cultures are negative? 1 Notify the Rapid Response Team. 2 Establish an IV for possible fluid administration. 3 Activate the bed alarm. 4 Reorient the patient frequently.

Notify the Rapid Response Team. Systemic inflammatory response syndrome (SIRS) manifests similarly to sepsis in which the patient is underperfused but an infectious cause may not be present. Worsening confusion suggests the patient is progressing in a shock state, and a Rapid Response Team should be called to assess and treat the patient's hypoperfusion. Establishing an IV for fluid administration is an appropriate action, but should not be done before calling the Rapid Response Team. Reorienting the patient and activating the bed alarm will not address the underlying cause of the confusion.

Which intervention would the nurse implement first for a patient who has been newly admitted for suspected septic shock? 1 Administer antibiotics. 2 Obtain blood cultures. 3 Assess the patient's bowel sounds. 4 Insert an indwelling urinary catheter.

Obtain blood cultures. Obtaining blood cultures should be the first intervention when septic shock is suspected. This should be done before administering antibiotics, so the physician can determine the best antibiotic to use to treat the patient. Inserting an indwelling catheter and assessing bowel sounds can occur after blood cultures have been obtained if necessary.

Which intervention would the nurse perform first for a patient who presents with sepsis and whose laboratory report shows a serum lactate level of 40 mg/dL? 1 Obtaining blood cultures 2 Providing mechanical ventilation 3 Administering crystalloids IV 4 Administering broad-spectrum antibiotics

Obtaining blood cultures The Surviving Sepsis Campaign (SSC) is a national initiative that was started to standardize sepsis care and promote early recognition of patients with sepsis and septic shock. Hour-1 bundle guidelines were developed to reduce sepsis-related deaths. The lactate level should be measured first (in this case, this was already done). Then the nurse would obtain blood cultures before administering broad-spectrum antibiotics. The nurse would then begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L (72 mg/dL). A patient with septic shock is likely to be mechanically ventilated; however, this is more likely as sepsis progresses to septic shock.

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action would the nurse delegate to assistive personnel (AP)? 1 Choosing appropriate oral fluids 2 Monitoring skin turgor for tenting 3 Offering fluids to drink every hour 4 Assessing oral mucosa for dryness

Offering fluids to drink every hour Encouraging a patient to take oral fluids is within the scope of practice for AP. Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor should be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.

A patient with which problem or condition is at highest risk for septic shock? 1 Obesity 2 Post uncomplicated appendectomy 3 Post myocardial infarction 4 On prednisone therapy for rheumatoid arthritis

On prednisone therapy for rheumatoid arthritis Patients who do not have intact immune systems are at highest risk for sepsis and septic shock, including those who have had organ transplants, with human immune deficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), kidney or liver disease, the very old, and those with invasive lines and procedures. Prednisone, taken for autoimmune diseases such as rheumatoid arthritis, suppresses the immune system and prevents further damage to the joints. Although obesity, surgery, and hospitalization for myocardial infarction pose some risk for infection and sepsis, the use of corticosteroid medications is an actual risk for the development of sepsis and septic shock.

Which organ is responsible for releasing myocardial depressant factor that leads to heart damage as a result of multiple organ dysfunction syndrome (MODS)? 1 Liver 2 Brain 3 Kidney 4 Pancreas

Pancreas Myocardial depressant factor is secreted from the ischemic pancreas and is responsible for causing profound damage to the heart in MODS. The liver, brain, and kidneys, in addition to the heart, are severely damaged, but they do not release myocardial depressant factors.

Which clinical finding is associated with severe sepsis? 1 Temperature of 98°F (36.7°C) 2 White blood cell (WBC) count of 10,000/mm3 3 Plasma glucose level of 140 mg/dL 4 Platelet count of 180,000/µL

Plasma glucose level of 140 mg/dL The continued stress response to sepsis triggers the continued release of glucose from the liver and causes hyperglycemia. Therefore more severe sepsis can elevate blood glucose levels. Blood glucose levels should be less than 100 mg/dL fasting, so a plasma glucose level of 140 mg/dL would indicate increased levels and would be associated with severe sepsis. Patients with severe sepsis can have hyperthermia and hypothermia but not typically a normal body temperature of 98°F (36.7°C). The WBC count elevates to more than 10,000/mm3 (normally 4,000-11,000/mm3) because of an increase in the inflammatory response. The platelet level (normally 150,000-400,000/uL) also decreases because of consumption of more amounts of available platelets and clotting factors, a condition called disseminated intravascular coagulation (DIC).

Which blood product is preferred for use to treat patients with septic shock? 1 Platelets 2 Clotting factors 3 Fresh-frozen plasma 4 Packed red blood cells

Platelets A patient in septic shock may have impaired clotting, increasing the risk for bleeding. Therefore the patient should be administered platelets to improve clotting and to prevent bleeding. The use of platelets for shock is recommended over other blood products such as clotting factors, fresh-frozen plasma, and packed red blood cells for a patient with septic shock because of their ability to improve clotting.

Which condition places a patient at highest risk for sepsis? 1 Pernicious anemia 2 Pericarditis 3 Post kidney transplant 4 Owning an iguana

Post kidney transplant The patient who underwent a kidney transplant will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the patient at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the patient with immunosuppression after a kidney transplant has a very high risk for infection, sepsis, and death.

Which condition is identified as a specific cause of distributive shock? Select all that apply. One, some, or all responses may be correct. 1 Sepsis 2 Cardiac tamponade 3 Anaphylaxis 4 Capillary leak 5 Pericarditis

Sepsis Anaphylaxis Capillary leak Distributive shock occurs when blood volume is not lost from the body but is distributed to the interstitial tissues where it does not circulate or deliver oxygen to the tissues. Sepsis (widespread infection that triggers a whole-body inflammatory response), anaphylaxis (widespread loss of blood vessel tone and decreased cardiac output), and capillary leak (response of capillaries to the presence of biologic mediators that change blood vessel integrity and allow fluid to shift from the blood vessels into the interstitial tissues) are all chemical-induced causes of distributive shock. Cardiac tamponade and pericarditis are the most common causes of obstructive shock, which is caused by problems that impair the ability of the normal heart muscle to pump effectively; the heart itself remains normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle.

Which type of shock is the nurse concerned about for a patient who has been refusing treatment for an infection for the past month? 1 Septic 2 Obstructive 3 Cardiogenic 4 Hypovolemic

Septic Infection can result in septic shock if it is not treated on time. Septic shock occurs when an infection is not confined to a local area, and it spreads into the blood stream and other body areas. Obstructive, cardiogenic, and hypovolemic shock are not caused by infection.

Which type of shock has no loss of blood volume from the body but has toxic metabolites that contribute to organ dysfunction? 1 Septic 2 Obstructive 3 Cardiogenic 4 Hypovolemic

Septic Septic shock is a type of distributive shock in which there is no blood volume loss, but low levels of oxygen are perfused to the body tissues because of infections. Obstructive shock is caused by problems that impair the ability of the normal heart to pump effectively. Although the heart remains healthy, the conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle. Cardiogenic shock occurs when the heart muscle is unhealthy, and pumping is impaired. Hypovolemic shock occurs when there is too little circulating blood volume, decreasing the mean arterial pressure (MAP) because of hemorrhage, which results in inadequate total body perfusion and oxygenation.

A patient with a history of hypertension asks the nurse what dietary changes are needed to control the blood pressure. Which item in the diet would the nurse recommend reducing? 1 Iron 2 Calcium 3 Sodium 4 Phosphorous

Sodium High sodium intake raises the serum sodium level, which causes more water to be retained. This, in turn, increases the blood volume and raises the blood pressure. Hence, patients who have hypertension are often asked to limit their intake of sodium. Intake of iron, phosphorus, or calcium does not cause water retention in the blood and therefore does not affect the blood pressure.

Which patient condition would likely cause increased renin secretion? 1 Sodium 130 mEq/L 2 Partial pressure of arterial oxygen (PaO2) 98% on room air 3 Blood pressure 130/82 mm Hg 4 Heart rate of 88 beats/min

Sodium 130 mEq/L A normal level of sodium in the blood is 136 to 145 mEq/L. Hyponatremia, as indicated by a sodium level of 130 mEq/L, would cause the kidneys to secrete renin to increase blood pressure and maintain perfusion and fluid balance. A PaO2 of 98% on room air, a blood pressure of 130/82 mm Hg, and a heart rate of 88 beats/min are all normal assessment findings and would not cause the secretion of renin.

IV colloid solutions contain which component that helps manage hypovolemic shock? 1 Salts 2 Sugars 3 Starches 4 Minerals

Starches Colloid solutions are mainly composed of larger molecules like starches and proteins. These molecules help maintain the oncotic pressure of the intravascular fluid and prevent fluid loss. Salts, sugars, and minerals are components of crystalloids, not colloids.

Which condition represents an early symptom of hypovolemic shock? 1 Hypotension 2 Bradypnea 3 Heart blocks 4 Tachycardia

Tachycardia Heart and respiratory rates increased from the patient's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the patient displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.

Which typical sign or symptom indicates the early stage of septic shock? 1 Pallor and cool skin 2 Blood pressure 84/50 mm Hg 3 Tachypnea 4 Polyuria

Tachypnea A patient in the early stage of septic shock often has mild hypotension, a low urine output, and an increased respiratory rate (tachypnea). In the early stage of septic shock, the patient is usually warm and febrile. More severe hypotension (as evidenced by blood pressure 84/50 mm Hg) does not develop until later in septic shock because of compensatory mechanisms. The patient will have a low urine output (not high urine output or polyuria) as a compensatory response to impaired gas exchange and perfusion.

A urine output of 13 mL/hr would indicate which condition? 1 The patient is normal. 2 The patient has septic shock. 3 The patient's urine output is increased. 4 The patient's urine output is decreased.

The patient's urine output is decreased. The patient's urine output is decreased because it is important to maintain a urine output of 20 mL/hr. The patient's condition is not normal because the output is decreased. In septic shock, the urine output decreases, but it is not the only criteria that indicates septic shock. The patient's urine output is not increased because healthy people should have a urine output of at least 30 mL/hr.

The nurse is reviewing the health record of a patient with hypovolemic shock. Which factor would the nurse suspect caused the decrease in perfusion? Select all that apply. One, some, or all responses may be correct. 1 Sepsis 2 Anemia 3 Warfarin 4 Heart failure 5 Hypertension

Warfarin Anticoagulants such as warfarin can decrease perfusion. Sepsis causes septic shock. Anemia causes hypoxia but not hypovolemic shock. Heart failure causes excess fluid. Hypertension increases vascular resistance but does not cause hypovolemic shock.

Which change in patient assessment over 2 days reflects that the administered diuretic is effective? 1 Weight decrease from 168 lb to 162 lb 2 Respiratory rate decrease from 24 breaths/min to 20 breaths/min 3 Urinary output decrease from 600 mL/8 hr to 200 mL/8 hr 4 Blood pressure decrease from 138/88 mm Hg to 126/78 mm Hg

Weight decrease from 168 lb to 162 lb Weight loss and increased urinary output are primary indicators of the effectiveness of a diuretic. In patients with edema, each pound of weight gained after the first pound equates to 500 mL of retained water, so if water loss occurs with diuretic therapy, weight loss will result. The changes in vital signs may reflect volume loss but are not the best indicators of the effectiveness of a diuretic.