NUR 216 Final Exam NEW MATERIAL

The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child's urine was orange. Which response by the nurse is accurate?

"An orange discoloration of urine is expected while your child is on this medication."

The nurse is caring for an older adult patient who is hospitalized with a second episode of pneumonia in the past 18 months. The patient has expressed frustration to the nurse and states, "I never got sick when I was younger. Why is this happening?" Which response by the nurse is most appropriate?

"As you grow older, there is a decrease in the immune response, which puts you at greater risk for developing an infection."

The school nurse is planning a teaching session with the parents of students to reduce the spread of the influenza virus throughout the school. What should the nurse include when teaching the parents of a diverse population about infection-control techniques? Select all that apply.

"Cover your cough" education Appropriate hand hygiene Sanitizing high-touch items to kill pathogens

The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to determine whether the patient is experiencing influenza? Select all that apply.

"Have you had a flu shot this year?" "Is your cough productive?" "Have you been exposed to anyone with the flu?"

The nurse makes a home visit to a patient recovering from complications related to influenza. Which patient statement indicates the need for further intervention by the nurse?

"I continue to wake up coughing at night."

The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement indicates that additional teaching is needed?

"I will get the pneumococcal vaccine every fall."

The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the patient makes which statement?

"Multiple drugs are necessary because of the risk of resistance."

An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB). The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most appropriate response by the nurse?

"There is an increased risk for a false-negative response for people who work in long-term care facilities. The two-step is recommended to accurately screen for TB."

A nurse is caring for an older adult patient admitted to the hospital with pneumonia. The patient asks the nurse what can be done to decrease the risk for developing pneumonia in the future. Which response by the nurse is inappropriate?

"You should drink a yogurt drink once a day that is supplemented with L. casei immunitas cultures."

20. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 480 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

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17. Which immunization should the nurse encourage for a patient who is diagnosed with Stage 2 human immunodeficiency virus? 1) Measles, mumps, and rubella (MMR) vaccine 2) Oral polio vaccine (OPV) 3) Influenza vaccine 4) Varicella vaccine

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1. The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is in antiretroviral therapy. The patient reports nausea, fever, severe diarrhea, and anorexia. Which prescribed medication does the nurse anticipate in order to relieve the anorexia and to stimulate the patient's appetite? 1) Dronabinol (Marinol) 2) Abacavir (Ziagen) 3) Ciprofloxacin (Cipro) 4) Zidovudine (Retrovir, AZT)

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13. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient presents with a fever without other notable symptoms. Which is the most likely cause of this data? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

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16. The nurse is assessing a patient who is diagnosed with human immunodeficiency virus (HIV) who presents with a rash. Which assessment question is most appropriate? 1) "Are you taking Bactrim?" 2) "Have you recently used a new soap?" 3) "What have you eaten in the last few days?" 4) "Did you have unprotected sex within the last week?"

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18. Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care? 1) Washing the injury under running water 2) Squeezing the site to remove the patient's blood 3) Taking two or three drugs for 28 days 4) Consenting to a human immunodeficiency virus (HIV) test

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21. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is less than 200 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

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3. The nurse is discharging a pediatric patient who was recently diagnosed with acquired immunodeficiency syndrome (AIDS). When discussing appropriate health promotion activities for this child, which immunization is contraindicated? 1) Varicella vaccine 2) Haemophilus influenzae type B (HIB conjugate vaccine) 3) Hepatitis B vaccine (hep B) 4) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

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5. The nurse is caring for a patient who is newly diagnosed with human immunodeficiency virus (HIV). The patient asks the nurse if there are ways to protect the patient's life partner from getting the HIV virus. After educating the patient, which statement indicates the need for further education? 1) "I know to use an oil-based lubricant to prevent spread of the disease to my partner." 2) "I can still kiss and hug my partner to show affection." 3) "I will not share my razor with my partner." 4) "I know I have to practice safer sex with my partner by using a latex condom."

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7. The nurse is providing care to a pediatric patient who is HIV-positive. The patient's mother is describing the child's current condition and activities to the nurse. Which parental statement indicates that the child may require further intervention? 1) "My child seems somewhat isolated and doesn't have any real friends." 2) "My child has a good appetite and eats regular meals." 3) "My child hasn't shown any sign of infection." 4) "My child attends school and doing well in class."

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26. Human immunodeficiency virus (HIV) infects and destroys CD4 cells. List the following events in the order in which they occur for a patient who is HIV-positive. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Virus invades helper T cell 2) Viral RNA converts with reverse transcriptase to viral DNA 3) Viral DNA integrates with host cell DNA. 4) Virus remains latent, or actively replicates 5) Virus sheds protein coat

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1. The nurse provides care to patients in the urgent care center. Which patient has the greatest risk for developing influenza? 1. A patient aged 26 years with a history of systemic lupus erythematosus (SLE) who works as an accountant 2. A patient aged 44 years who is a nurse 3. A patient aged 60 years with a history of asthma 4. A patient aged 66 years with a history of diabetes mellitus

1. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 1. Describing the epidemiology of infectious airway disorders Chapter page reference: 461 - 462 Heading: Influenza/Epidemiology/ Table 24.1 Risk Factors for Influenza Infection Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This patient has one risk factor for developing influenza (a history of asthma). There is another patient with a greater risk. 2 This patient has one risk factor for developing influenza (healthcare provider occupation). There is another patient with a greater risk. 3 This patient has one risk factor for influenza (chronic health condition). There is another patient with a greater risk. 4 This patient has two risk factors for influenza (age and diabetes); therefore, this patient is at the greatest risk for developing influenza.

Sepsis Bundle

1. Draw labs: Lactate (measures the progression of sepsis; if above 2 needs to be repeated), blood cultures 2. Give antibiotics (broad spectrum) 3. Give fluid bolus 4. Give vasopressors if needed

Who is at risk for sepsis

1. Patients on chemo 2. Diabetic patients 3. Immunodeficient patients 4. Surgical patients a. Perforate bowel b. Bowel surgeries 5. UTI patients 6. Pneumonia patients

12. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a teaching session for this patient regarding this occurrence? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

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10. Which statement by the patient being discharged after hospitalization for influenza indicated the need for further teaching? 1. "I do not need to get a flu shot next year because I am now immune." 2. "I still need to get flu shots every year." 3. "I understand that the flu vaccine changes every year." 4. "I need to get my flu shot every year in the early fall."

10. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 6. Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 464 - 466 Heading: Influenza/Nursing Interventions/Teaching Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Infection Difficulty: Moderate Feedback 1 This statement indicates the need for further teaching as this patient is not immune. The influenza virus changes every year and so does the vaccine. Treatment for influenza is directed primarily toward prevention by annual vaccination. Inoculation by inactivated influenza viruses that were identified as causing outbreaks the preceding year can provide up to 80% protection from the projected upcoming year's virus. 2 This statement indicates understanding of teaching as treatment for influenza illness is directed primarily toward prevention by annual vaccination. 3 This statement indicates understanding of teaching as inoculation by inactivated influenza viruses that were identified as causing outbreaks the preceding year can provide up to 80% protection from the projected upcoming year's virus. 4 This statement indicates understanding of teaching because the most appropriate time of year for vaccination is in the early fall before the "flu season" begins.

11. The nurse is preparing an educational program pneumonia and includes information about which pathogen that is the major pathogen associated with hospital-acquired pneumonia (HAP)? 1. Haemophilus influenzae 2. Mycoplasma pneumoniae 3. Pseudomonas aeruginosa 4. Streptococcus pneumoniae

11. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 1. Describing the epidemiology of infectious airway disorders Chapter page reference: 466 - 467 Heading: Pneumonia/Epidemiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Infection Difficulty: Moderate Feedback 1 Haemophilus influenzae, Mycoplasma pneumoniae, and Streptococcus pneumoniae are examples of common causative organisms for community-acquired, not hospital-acquired, pneumonia. 2 Haemophilus influenzae, Mycoplasma pneumoniae, and Streptococcus pneumoniae are examples of common causative organisms for community-acquired, not hospital-acquired, pneumonia. 3 Pseudomonas aeruginosa is the major pathogen associated with hospital-acquired pneumonia (HAP). 4 Haemophilus influenzae, Mycoplasma pneumoniae, and Streptococcus pneumoniae are examples of common causative organisms for community-acquired, not hospital-acquired, pneumonia.

12. How does the nurse interpret the following arterial blood gases in the patient admitted with influenza? pH 7.48 PaO2 85 mm Hg PaCO2 30 mm Hg HCO3 24 mEq/L 1. Respiratory alkalosis 2. Respiratory acidosis 3. Hypoxemia 4. Normal arterial blood result

12. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 2. Correlating clinical manifestations to pathophysiological processes of influenza. Chapter page reference: 468 Heading: Pneumonia/Medical Management/Diagnosis Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Moderate Feedback 1 Primary respiratory infections may initially cause a respiratory alkalosis (increased pH, decreased carbon dioxide [CO2]) in response to increased respiratory rate. 2 In respiratory acidosis, there is a decreased pH and increased carbon dioxide [CO2]). 3 Because the PaO2 is within normal limits, this is not consistent with hypoxemia. 4 This is not a normal arterial blood gas because the pH is above normal range and the PaCO2 is low.

13. In reviewing arterial blood gas results on a patient admitted with a severe influenza infection, the nurse correlates which value to the patients' respiratory acidosis? 1. pH 7.50 2. PaO2 75 mm Hg 3. PaCO2 50 mm Hg 4. O2 Saturation 88%

13. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 2. Correlating clinical manifestations to pathophysiological processes of Chapter page reference: 468 Heading: Pneumonia/Medical Management/Diagnosis Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Moderate Feedback 1 This pH is consistent with an alkalosis. 2 The PaO2 is low but does not have a direct effect on the acid-base status. 3 Primary respiratory infections may initially cause a respiratory alkalosis (increased pH, decreased carbon dioxide [CO2]) in response to increased respiratory rate. As the condition progresses, a respiratory acidosis (decreased pH, increased CO2) will develop. 4 The O2 saturation is low but does not have a direct effect on the acid-base status.

14. The nurse recognizes which medication is indicated to treat community-acquired pneumonia in the patient who was previously healthy and has not received antibiotics in the last 3 months? 1. β-Lactam antibiotics 2. Macrolides 3. Respiratory fluoroquinolones 4. Vancomycin

14. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 4. Discussing the medical management of pneumonia. Chapter page reference: 468 Heading: Pneumonia/Medications Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Medication Difficulty: Moderate Feedback 1 β-Lactam antibiotics and respiratory fluoroquinolones are indicated for the treatment of all inpatients with a community-acquired pneumonia (CAP). 2 Macrolides are indicated in the treatment of CAP in patients who were previously healthy and not treated with antibiotics in the previous 3 months. 3 β-Lactam antibiotics and respiratory fluoroquinolones are indicated for the treatment of all inpatients with a community acquired pneumonia. 4 Vancomycin is used to treat methicillin-resistant Staphylococcus aureus community-acquired pneumonia.

A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (Record your answer using a whole number.) ____ mL/hr

142 mL/hr ~ The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30 mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr (3409/24 = 142).

15. The nurse is caring for a patient who was recently treated for an empyema that developed secondary to pneumonia. Which procedure does the nurse prepare the patient to decrease recurrence once the empyema has been drained? 1. Bronchoscopy 2. Chest tube insertion 3. Pleurodesis 4. Thoracentesis

15. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 4. Discussing the medical management of pneumonia. Chapter page reference: 468 - 469 Heading: Pneumonia/Complications Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Infection Difficulty: Difficult Feedback 1 An empyema is a collection of purulent material in the pleural space, and a bronchoscopy is used to visualize the bronchioles. 2 The chest tube insertion is the procedure used to drain the empyema, a collection of purulent material in the pleural space. 3 Pleurodesis is the injection of a sclerosing or scarring agent into the pleural space, causing the visceral and parietal pleura to "stick together," and may be performed after the empyema has been resolved to prevent recurrence. 4 Thoracentesis is a procedure to remove fluid from the pleural space but does not decrease chances of recurrence.

16. The nurse develops the nursing diagnosis, "Ineffective Airway Clearance related to thick purulent secretions." This nursing diagnosis is most relevant to the patient with which medical diagnosis? 1. Tuberculosis 2. Bacterial pneumonia 3. Influenza A 4. Influenza C

16. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 5. Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 469 Heading: Pneumonia/Nursing Interventions/Assessment Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Secretions/sputum in patients with tuberculosis are typically rust colored. 2 Secretions in bacterial pneumonia are usually purulent and/or bloody secretions that result from buildup of exudate in the alveoli. 3 Secretions that are white are consistent with viral influenza. 4 Influenza C typically causes either no symptoms at all or a very mild respiratory illness.

17. On assuming care for a patient being treated for bacterial pneumonia, which assessment finding requires immediate attention by the nurse? 1. Fever 2. Productive cough 3. Restlessness 4. Arthralgia

17. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 2. Correlating clinical manifestations to pathophysiological processes of pneumonia. Chapter page reference: 469 Heading: Pneumonia/Nursing Interventions/Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Assessment Difficulty: Difficult Feedback 1 Clinical manifestations of bacterial pneumonia include fever, chills, tachypnea, tachycardia, cough (productive or non-productive), pleuritic pain, fatigue, and myalgias. Dyspnea, particularly at rest, is an indication that the patient's respiratory status is deteriorating. 2 Clinical manifestations of bacterial pneumonia include fever, chills, tachypnea, tachycardia, cough (productive or non-productive), pleuritic pain, fatigue, and myalgias. Dyspnea, particularly at rest, is an indication that the patient's respiratory status is deteriorating. 3 Agitation, restlessness, anxiety, lethargy, and fatigue are the result of decreased tissue perfusion from altered alveolar gas exchange and require immediate action by the nurse. 4 Clinical manifestations of bacterial pneumonia include fever, chills, tachypnea, tachycardia, cough (productive or non-productive), pleuritic pain, fatigue, and myalgias. Dyspnea, particularly at rest, is an indication that the patient's respiratory status is deteriorating.

18. The nurse is caring for a patient hospitalized for a severe bacterial pneumonia with a left lung infiltration. In what position does the nurse place the patient to maximize perfusion to functional alveolar units? 1. Prone 2. Supine with head of bed elevated 30 degrees 3. On the left side 4. On the right side

18. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 5. Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 470 Heading: Pneumonia/Nursing Interventions/Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Difficult Feedback 1 The prone position is not best to promote alveolar perfusion. 2 Elevating the head of the bed facilitates breathing effort and minimizes risk of aspiration but does not promote alveolar perfusion. 3 For infiltrates of only one lung, when turning, preferentially position the patient with the good lung down to maximize perfusion to functional alveolar units. Because this patient has a left lung infiltrate, the right side is preferred. 4 For infiltrates of only one lung, when turning, preferentially position the patient with the good lung down to maximize perfusion to functional alveolar units. Because this patient has a left lung infiltrate, the right side is preferred.

19. The nurse monitors for which clinical manifestation in the patient admitted with tuberculosis? 1. Greenish-colored sputum 2. Rust-colored sputum 3. Whitish-colored sputum 4. Yellowish-colored sputum

19. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 2. Correlating clinical manifestations to pathophysiological processes of tuberculosis. Chapter page reference: 471 Heading: Tuberculosis/Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback 1 Green- and yellow-colored sputum is consistent with bacterial infections. 2 Blood-tinged or rust-colored sputum is present as a result of the destruction of lung parenchyma tissue. 3 Secretions that are white are consistent with viral infections and often associated with influenza. 4 Green- and yellow-colored sputum is consistent with bacterial infections.

6. A home health nurse is conducting home visits for several patients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which patient would the nurse see first? 1) A patient who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count 2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath 3) A patient with wasting syndrome who needs modifications and education regarding dietary changes 4) A patient who is receiving IV antibiotics daily for toxoplasmosis

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9. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 500 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

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28. The nurse is reviewing the laboratory values of a patient who is newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which values should be reported to the patient's health-care provider? Select all that apply. 1) CD4 cell count 1,100/mm3 2) T4 cell count 150 3) CD4 lymphocytes 12% 4) Viral load 11,500 copies/mL 5) WBC 6,500

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27. The nurse is planning care for a pediatric patient diagnosed with human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric patient. Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply. 1) Administering tuberculosis skin tests every six months 2) Teaching proper food-handling techniques to the family 3) Instructing on the importance of consuming ample fresh fruits and vegetables 4) Assessing the health status of all visitors 5) Monitoring hand-washing techniques used by the family

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2. Which statement by the patient recently diagnosed with an influenza infection indicates that teaching was effective? 1. "I am infectious for 4 days." 2. "I am infectious for up to 10 days." 3. "I am not infectious now that I am on antibiotics." 4. "I am not infectious unless I cough up a lot of secretions."

2. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 6. Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 461 - 462 Heading: Influenza/Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Infection Difficulty: Moderate Feedback 1 The patient is infectious for up to 7 to 10 days, not 4 days. 2 Virus shedding usually ends 2 to 5 days after symptoms first appear; therefore, it is important to remember that individuals are infectious for up to 7 to 10 days. 3 The patient is still infectious for up to 7 to 10 days even on antibiotics. 4 Because influenza is an airborne pathogen, it does not require a cough to spread.

20. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding correlates with this diagnosis? 1. Wheezing 2. Hemoptysis 3. Yellowish sputum 4. Slightly whitish sputum

20. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 2. Correlating clinical manifestations to pathophysiological processes tuberculosis Chapter page reference: 471 Heading: Tuberculosis/Clinical Manifestations/Symptomatic TB Infection Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy Feedback 1 Wheezing is the term used to describe the musical sounds auscultated during assessment and indicates some degree of airway obstruction that occurs with asthma and emphysema. 2 Tuberculosis is characterized by hemoptysis, which is the term for coughing up of blood or blood-tinged sputum from the respiratory tract. 3 Yellowish sputum is associated with bacterial infections. 4 Clear, slightly whitish, and viscous sputum are often normal findings.

21. On assuming care for a patient being treated for tuberculosis, which assessment finding requires immediate attention by the nurse? 1. Dyspnea 2. Fatigue 3. Night sweats 4. Rust-colored sputum

21. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 2. Correlating clinical manifestations to pathophysiological processes of Chapter page reference: 471 Heading: Symptomatic TB infection Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 Initial symptoms of tuberculosis (TB) are relatively nonspecific and consist of fatigue, weight loss, and night sweats, followed by the development of a cough that produces a rusty-colored or blood-streaked sputum. As the disease progresses, dyspnea, orthopnea, and rales become evident as signs of respiratory compromise. 2 Initial symptoms of tuberculosis are relatively nonspecific and consist of fatigue, weight loss, and night sweats. 3 Initial symptoms of tuberculosis are relatively nonspecific and consist of fatigue, weight loss, and night sweats. 4 Patients with symptomatic TB develop a cough that produces a rusty-colored or blood-streaked sputum. This is an expected finding in the patient with TB.

22. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is greater than 500 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

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24. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Which patient statement indicates the need for further education regarding HIV management? 1) "I will eat small, frequent meals." 2) "I will use condoms for every sexual encounter." 3) "I will take my medications when others can see me, even if that means taking them late." 4) "I will ask my spouse to clean the cat litter to decrease my risk for developing toxoplasmosis."

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4. A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus (HIV). The patient states, "I don't plan on giving up sex just because I am HIV positive." Based on this data, which is the priority nursing diagnosis for this patient? 1) Risk for Infection 2) Death Anxiety 3) Deficient Knowledge 4) Social Isolation

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8. A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement when providing direct care? 1) Droplet 2) Reverse 3) Standard 4) Contact

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22. The nurse reads tuberculin skin test (TST) results for a group of patients. Which patient does the nurse document as a positive result in the medical record? 1. The adult patient diagnosed with HIV whose induration is 3 mm. 2. The adult who recently had contact with a person with tuberculosis whose induration is 4 mm. 3. The patient who uses intravenous (IV) drugs whose induration is 11 mm. 4. The adult who recently immigrated from a high-prevalence country whose induration is 8 mm.

22. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 3. Describing the diagnostic results used to confirm the diagnosis of infectious airway disorders Chapter page reference: 472 - 473 Heading: Tuberculosis/Medical Mgmt/Treatment/Table 24.7 Classification of Tuberculin Skin Test Reactions Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 A patient diagnosed with HIV requires an induration of 5 mm or greater for the nurse to document a positive result in the medical record. 2 A person who recently had contact with a person with tuberculosis requires an induration of 5 mm or greater for the nurse to document a positive result in the medical record. 3 This patient's result is considered positive, necessitating the nurse to document a positive result in the medical record. The patient who uses intravenous drugs has a positive result for an induration of 10 mm or greater. 4 A tuberculin skin test for a patient with immunosuppression is considered positive when the induration is 5 mm or greater.

23. The nurse working in the community health clinic places a purified protein derivative (PPD, or Mantoux) test on an adult's forearm and instructs him to return when for reading of the response? 1. The following day 2. Between 24 and 48 hours after placement of the PPD 3. Between 48 and 72 hours after placement of the PPD 4. Between 72 and 96 hours after placement of the PPD

23. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 3. Describing the diagnostic results used to confirm the diagnosis of infectious airway disorders Chapter page reference: 471 - 472 Heading: Tuberculosis/Diagnosis Integrated Processes: Nursing Process: Evaluation Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 Within 48 to 72 hours after injection of the purified protein derivative (PPD), the administration site should be observed for any reaction. This is too early. 2 Within 48 to 72 hours after injection of the PPD, the administration site should be observed for any reaction. This is too early. 3 The skin test is a positive purified protein derivative (PPD) screen skin test, also called a Mantoux test. The test is administered by injecting 0.1 mL of PPD intradermally into the tissue of the forearm. Within 48 to 72 hours after injection, the administration site should be observed for any reaction. 4 Within 48 to 72 hours after injection of the PPD, the administration site should be observed for any reaction. This is too late.

24. The nurse is caring for a patient who is admitted to the unit with tuberculosis (TB). The patient is placed in isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most appropriate? 1. Single-door room with positive air flow (air flows out of the room) 2. Isolation room with an anteroom and negative air flow (air flows into the room) 3. Isolation room with an anteroom and normal airflow 4. Single-door room with normal airflow

24. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 4. Discussing the medical management of tuberculosis Chapter page reference: 472 Heading: Tuberculosis/Treatment/Safety Alert Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Positive flow rooms are used for those patients who are immunosuppressed so that microorganisms from the unit are not drawn into the room. 2 Patients with airborne infections such as meningococcemia, severe acute respiratory syndrome (SARS), or tuberculosis are placed in an isolation room with an anteroom and negative pressure airflow. Air flows into the room and is vented in a special manner to prevent the organism from entering the rest of the unit. 3 Single-door isolation with normal airflow might be used for a patient with droplet or wound infection. 4 Single-door rooms are not equipped to have positive or negative airflow.

25. Which statement made by the patient with an active tuberculosis (TB) infection who is discharged to home receiving directly observed therapy indicates that teaching was effective? 1. "The home-health nurse will come to my home daily to make sure that I take my medications." 2. "I need to be on home isolation for about 2 weeks." 3. "I only have to take these medications for about 6 months." 4. "I will not need to be tested for TB after the infection is cured."

25. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 6. Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 474 Heading: Tuberculosis/Transitional Care Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Difficult Feedback 1 Once the patient with tuberculosis (TB) has been stabilized and has started on therapy, treatment can continue at home. National TB treatment guidelines strongly recommend using directly observed therapy (DOT) when treating persons with active TB disease. DOT is in place when a trained healthcare worker, home healthcare nurse, aide, or designated and trained individual provides the prescribed TB drugs and watches the patient swallow every dose. 2 The need for home isolation may last up to 6 weeks depending on the patient's response to therapy. 3 The medication regimen for TB is between 9 and 12 months. 4 The patient will continue to need to be tested for TB even after treatment is completed because reinfection is possible.

11. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of less than 200 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

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15. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has shortness of breath when walking, but no problems breathing at rest. Which is the most likely cause for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

4

26. The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to determine whether the patient is experiencing influenza? Select all that apply. 1. "Have you had a flu shot this year?" 2. "Is your cough productive?" 3. "Have you been exposed to anyone with the flu?" 4. "Have you had a recent weight loss?" 5. "Do you have dizziness?"

26. ANS: 1, 2, 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 2. Correlating clinical manifestations to pathophysiological processes of: Influenza Chapter page reference: 462 Heading: Influenza/Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback 1 This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. 2 This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. 3 This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. 4 This is incorrect. Unexplained weight loss is not typically observed in patients with influenza. This is more symptomatic of tuberculosis.

27. A patient is with a severe influenza infection is placed on droplet precautions. What actions by the nurse are relevant for this type of isolation? Select all that apply. 1. N95 mask 2. Surgical mask 3. Negative airflow room 4. Private room 5. Gown and gloves

27. ANS: 2, 4, 5 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 4. Discussing the medical management of pneumonia Chapter page reference: 464 Heading: Influenza/Nursing Interventions/Actions Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is incorrect. N95 mask respirators, negative airflow rooms, and/or high-efficiency particulate air (HEPA) filtered rooms are required for airborne precautions. Patients with tuberculosis (TB) require airborne precautions. 2 This is correct. Patients are placed on droplet precautions to avoid viral transmission. Personal protective equipment required includes mask, gown, gloves, and eye protection if there is a risk of splash of body fluids. The patient should wear a mask when outside the room. Visitors should wear a mask while in the room. A private room is desirable unless patients with similar infections are cohorted. 3 This is incorrect. N95 mask respirators, negative airflow rooms, and/or HEPA filtered rooms are required for airborne precautions. Patients with TB require airborne precautions. 4 This is correct. Patients are placed on droplet precautions to avoid viral transmission. Personal protective equipment required includes mask, gown, gloves, and eye protection if there is a risk of splash of body fluids. The patient should wear a mask when outside the room. Visitors should wear a mask while in the room. A private room is desirable unless patients with similar infections are cohorted. 5 This is correct. Patients are placed on droplet precautions to avoid viral transmission. Personal protective equipment required includes mask, gown, gloves, and eye protection if there is a risk of splash of body fluids. The patient should wear a mask when outside the room. Visitors should wear a mask while in the room. A private room is desirable unless patients with similar infections are cohorted.

28. The school nurse is planning a teaching session with the parents of students to reduce the spread of the influenza virus throughout the school. What should the nurse include when teaching the parents about minimizing the chance of spread of influenza? Select all that apply. 1. "Cover your cough" education 2. Appropriate hand hygiene 3. Safe food preparation and storage 4. Sanitizing high-touch items to kill pathogens 5. Getting the influenza vaccine in the early summer

28. ANS: 1, 2, 4 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 6. Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 464 - 466 Heading: Influenza/Nursing Interventions/Teaching Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as "cover your cough" education all control the growth and spread of microorganisms. 2 This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as "cover your cough" education all control the growth and spread of microorganisms. 3 This is incorrect. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. 4 This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as "cover your cough" education all control the growth and spread of microorganisms. To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. 5 This is incorrect. The most appropriate time of year for vaccination is in the early fall before the "flu season" begins.

____ 29. The nurse correlates which risk factors with tuberculosis? Select all that apply. 1. Homelessness 2. Incarceration 3. Caucasian race 4. Hispanic race 5. Obesity

29. ANS: 1, 2, 4 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 1. Describing the epidemiology of infectious airway disorders Chapter page reference: 470 - 471 Heading: Tuberculosis/Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 This is correct. Populations at risk for tuberculosis (TB) include low socioeconomic groups with obstacles to accessing healthcare, the homeless, and incarcerated populations. There is an increased incidence among blacks, Hispanics, and Asians. Immunosuppression is also a risk factor for TB. 2 This is correct. Populations at risk for tuberculosis include low socioeconomic groups with obstacles to accessing healthcare, the homeless, and incarcerated populations. There is an increased incidence among blacks, Hispanics, and Asians. Immunosuppression is also a risk factor for TB. 3 This is incorrect. Races at increased risk of TB include blacks, Hispanics, and Asians, not Caucasians. 4 This is correct. Populations at risk for tuberculosis include low socioeconomic groups with obstacles to accessing healthcare, the homeless, and incarcerated populations. There is an increased incidence among blacks, Hispanics, and Asians. Immunosuppression is also a risk factor for TB. 5 This is incorrect. Obesity is not a risk factor for TB.

10. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 300 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

3

14. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient reports night sweats. Which is the most likely reason for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

3

3. The nurse working in the emergency department recognizes that the results of a rapid influenza diagnostic test (RIDT) is usually available within which time frame? 1. 30 minutes 2. 60 minutes 3. 12 hours 4. 24 hours

3. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 3. Describing the diagnostic results used to confirm the diagnosis of infectious airway disorders Chapter page reference: 462 Heading: Influenza/Medical Management/Diagnosis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Infection Difficulty: Easy Feedback 1 In emergency departments and outpatient clinics, the most commonly used tests for influenza are rapid influenza diagnostic tests (RIDTs). The identification of an influenza virus infection can be made in less than 30 minutes via nasopharyngeal/throat swab or nasal washings/aspirate. 2 The identification of an influenza virus infection can be made in less than 30 minutes via nasopharyngeal/throat swab or nasal washings/aspirate. 3 The identification of an influenza virus infection can be made in less than 30 minutes via nasopharyngeal/throat swab or nasal washings/aspirate. 4 The identification of an influenza virus infection can be made in less than 30 minutes via nasopharyngeal/throat swab or nasal washings/aspirate.

30. The nurse caring for a homeless patient at risk for tuberculosis (TB) includes which clinical manifestations of the disease when educating the patient? Select all that apply. 1. Fatigue 2. Green-tinged sputum 3. Productive cough that later turns to a dry, hacking cough 4. Weight loss 5. Night sweats

30. ANS: 1, 4, 5 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 6. Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 471 Heading: Tuberculosis/Pathophysiology and Clinical Manifestations/Symptomatic TB Infection Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Nursing Roles Difficulty: Moderate Feedback 1 This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention. 2 This is incorrect. Rusty-colored, not greenish, sputum occurs as a result of the destruction of lung tissue during granuloma formation. 3 This is incorrect. A dry cough develops, which later becomes productive of purulent and/or blood-tinged sputum. 4 This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention. 5 This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention.

31. Which interventions does the nurse implement when providing care for a patient who is admitted for the treatment of active tuberculosis? Select all that apply. 1. Places the patient on droplet precautions 2. Wears a surgical mask when providing patient care 3. Places the patient in a private, negative airflow room 4. Wears eye protection when collecting sputum samples 5. Places a surgical mask on the patient to transport to radiology

31. ANS: 3, 4, 5 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 5. Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 472 Heading: Tuberculosis/Treatment/Safety Alert Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Difficult Feedback 1 This is incorrect. The patient who is admitted for the treatment of active tuberculosis requires airborne, not droplet, precautions. 2 This is incorrect. The nurse wears an N95 mask when providing care to the patient with active tuberculosis. 3 This is correct. Immediate isolation of the patient with suspected or confirmed TB infection in a private room with negative airflow capabilities is a priority. Negative airflow occurs when air moves into the contaminated area or into the patient's room from bordering areas. 4 This is correct. Eye protection is personal protective equipment that is used for implementing standard precautions when respiratory sprays may occur. This is an appropriate nursing action. 5 This is correct. The patient's movement and transportation to other departments should be limited to essential needs only. Patients who must leave the negative pressure room should also wear a surgical mask.

32. In providing teaching for a patient recently diagnosed with an active tuberculosis (TB) infection, the nurse incorporates teaching about which medications? Select all that apply. 1. Ethambutol 2. Isoniazid 3. Pyrazinamide 4. Rifampin

32. ANS: 1, 2, 3, 4 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 4. Discussing the medical management of tuberculosis Chapter page reference: 472 - 473 Heading: Tuberculosis/Treatment/Table 24.8 Recommended Tuberculosis Treatment Regimens Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Medication Difficulty: Moderate Feedback 1 This is correct. Treatment for tuberculosis (TB) includes a basic four-drug combination that continues for 9 to 12 months. The medications include ethambutol, isoniazid, pyrazinamide, and rifampin. 2 This is correct. Treatment for TB includes a basic four-drug combination that continues for 9 to 12 months. The medications include ethambutol, isoniazid, pyrazinamide, and rifampin. 3 This is correct. Treatment for TB includes a basic four-drug combination that continues for 9 to 12 months. The medications include ethambutol, isoniazid, pyrazinamide, and rifampin. 4 This is correct. Treatment for TB includes a basic four-drug combination that continues for 9 to 12 months. The medications include ethambutol, isoniazid, pyrazinamide, and rifampin.

19. Which patient should the nurse offer the opportunity for human immunodeficiency virus (HIV) testing during an annual physical examination? 1) A 66-year-old male patient 2) A 75-year-old female patient 3) An 8-year-old school-age child 4) An 18-year-old young adult patient

4

2. A nurse is performing an admission assessment on a patient with symptoms that indicate human immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting HIV? 1) "Has your partner been experiencing these symptoms?" 2) "When was your first sexual experience?" 3) "Have you had any fever, diarrhea, or chills over the last 48 hours?" 4) "Have you ever experimented with intravenous drugs?"

4

23. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 250 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

4

25. Place the progression of human immunodeficiency virus (HIV) in sequential order. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) AIDS 2) Death 3) Seroconversion 4) Viral transmission 5) Acute viral infection 6) Asymptomatic chronic infection

4 3 5 6 1 2

4. The nurse is assessing several patients at a community clinic. The nurse questions administration of the annual influenza vaccination in which patient? 1. A 3-year-old with cystic fibrosis 2. A 25-year-old pregnant woman at 20 weeks' gestation 3. A 35-year-old man with a severe allergy to eggs 4. A 65-year-old woman with diabetes

4. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 1. Describing the etiology of infectious airway disorders Chapter page reference: 463 Heading: Influenza/Epidemiology and Med Mgmt/Treatment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Infection Difficulty: Moderate Feedback 1 Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary diseases, are more susceptible to complications from the flu; therefore, this patient should receive an annual influenza vaccine. 2 Pregnant women, particularly during the second and third trimesters, are at increased risk of complications from the flu; therefore, this patient should receive the annual influenza vaccine. 3 A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the annual vaccine contains an inactive ingredient with an egg protein. This patient needs to be assessed for an alternative form of vaccine without this egg protein. 4 People at increased risk of influenza or its complications include infants, young children, and anyone age 50 or older; therefore, this patient should receive an annual influenza vaccine.

5. The nurse provides education to a patient who is prescribed an antiviral medication, oseltamivir (Tamiflu), for the treatment of influenza. Which patient statement indicates to the nurse a correct understanding of the administration of this medication? 1. "This medication is administered by an IV." 2. "This medication is administered by mouth." 3. "This medication is administered by injection." 4. "This medication is administered by inhalation."

5. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 4. Discussing the medical management of influenza. Chapter page reference: 463 Heading: Influenza/Treatment/Table 24.3 Antiviral Medications for the Treatment of Influenza Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Medication Difficulty: Easy Feedback 1 Peramivir (Rapivab), not oseltamivir, is administered intravenously. 2 This statement indicates a correct understanding for the administration of oseltamivir. 3 This medication is administered orally, not by injection. 4 Zanamivir (Relenza), not oseltamivir, is administered by inhalation.

6. The nurse correlates which clinical manifestation as the earliest compensatory mechanism in the patient with influenza? 1. Oliguria 2. Tachycardia 3. Tachypnea 4. Fever

6. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 2. Correlating clinical manifestations to pathophysiological processes of influenza. Chapter page reference: 464 Heading: Influenza/Nursing Interventions/Assessments Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback 1 Decreased urine output may develop secondary to increased insensitive fluid loss but is not a compensatory mechanism. 2 Tachycardia to raise the heart rate is the second compensatory mechanism for the continued impairment of oxygen delivery. 3 Tachypnea, increased respiratory rate and depth, is the body's first compensatory mechanism to decreased oxygen delivery. 4 Fever occurs as a part of the inflammatory response but is not the earliest sign.

7. The patient recently released from the hospital after recovering from complications related to influenza is being seen in the outpatient clinic. Which patient statement indicates the need for further intervention? 1. "I went back to work." 2. "I am drinking at least 8 glasses of water daily. " 3. "I continue to wake up coughing at night." 4. "I only had a low-grade fever once since I left the hospital."

7. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 5. Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 464 - 466 Heading: Influenza/Nursing Interventions/Assessment & Teaching Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Moderate Feedback 1 The patient is allowed to return to work once cleared by the provider and having no clinical manifestations of complications. 2 Adequate fluid intake is important to facilitate decreasing viscosity of secretions for expectoration. 3 A patient who continues to be awakened during the night because of coughing requires further assessment, particularly in relation to the color and viscosity of secretions. Primary viral pneumonia from influenza can cause coughing that lasts up to 2 weeks. Secretions that are white are consistent with viral infection. Purulent nasal discharge/sputum indicates a secondary bacterial infection. 4 This patient statement does not indicate the need for further intervention by the nurse.

8. The nurse questions which order for the patient admitted with the flu who is experiencing tachypnea? 1. Maintain adequate hydration. 2. Keep the head of the bed elevated. 3. Teach the patient coughing, deep breathing, and hydration. 4. Prepare the patient for intubation.

8. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 5. Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 464 Heading: Influenza/Nursing Interventions/Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Coughing, deep breathing, and hydration are essential for achieving airway clearance. 2 Keeping the head of the bed elevated improves lung excursion and reduces the work of breathing. 3 Coughing, deep breathing, and hydration are essential for achieving airway clearance. 4 This patient is experiencing tachypnea and there are no data (difficulty maintaining an airway, decreased oxygen saturation, etc.) that support that the patient requires intubation at this time.

TB Medications

9-12 month medication regimen Modifications for special populations

9. The nurse is planning care for a patient diagnosed with influenza. Which intervention by the nurse is the priority when planning this patient's care? 1. Restricting all visits from family and friends 2. Providing staff with N95 mask respirators 3. Placing the patient in a negative air flow room 4. Placing the patient on droplet precaution

9. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients with Infectious Respiratory Disorders Chapter learning objective: 5. Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 464 - 466 Heading: Influenza/Nursing Interventions/Actions & Teaching Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Visitation may be limited, especially during the first few days, but visitation is not totally restricted. Visitors should wear a mask while in the room. 2 N95 mask respirators are indicated for patients on airborne precautions. Patients with influenza ae placed on droplet and contact precautions. 3 Negative air flow rooms are for diseases such as chicken pox, measles, and severe acute respiratory syndrome (SARS). 4 To prevent the spread of influenza, the patient is placed in a private room with signs for droplet and contact precautions. It is appropriate for the healthcare workers to use appropriate personal protective equipment (PPE) for these transmission-based precautions. Place patient in droplet precautions to avoid viral transmission. Personal protective equipment required includes mask, gown, gloves, and eye protection if there is a risk of splash of body fluids.

The nurse is assessing several patients at a community clinic. Which patient should not receive an annual influenza vaccination?

A 65-year-old woman

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a. Assess the blood pressure by Doppler. b. Estimate the systolic pressure as 60 mm Hg. c. Obtain an electronic blood pressure monitor. d. Record the blood pressure as not assessable.

A ~ Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is not appropriate without further attempts using different modalities.

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5

A ~ Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are high and would not indicate an appropriate response to therapy.

After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5 F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which active physician order first? a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg. b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101 F.

A ~ Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated.

The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101 F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? a. Insertion of an 18-gauge peripheral intravenous line b. Application of cushioned heel protectors c. Implementation of fall precautions d. Implementation of universal precautions

A ~ Given the patient's diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration. Universal precautions, fall precautions, and application of heel protectors are appropriate interventions but are not the immediate priority.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. High glucose is common in shock and needs to be treated. b. Some of the medications we are giving are to raise blood sugar. c. The IV solution has lots of glucose, which raises blood sugar. d. The stress of this illness has made your spouse a diabetic.

A ~ High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not made the client diabetic.

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance

A ~ In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central line associated bloodstream infection (CLABSI)? a. Documentation of insertion date b. Elevation of the head of the bed c. Assessment for weaning readiness d. Appropriate sedation management

A ~ Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia.

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert & oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

A ~ Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a. Dobutamine (Dobutrex) b. Furosemide (Lasix) c. Phenylephrine (Neo-Synephrine) d. Sodium nitroprusside (Nipride)

A ~ Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.

The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? a. The action of the machine will improve blood supply to the damaged heart. b. The machine will beat for the damaged heart with every beat until it heals. c. The machine will help cleanse the blood of impurities that might damage the heart. d. The machine will remain in place until the patient is ready for a heart transplant.

A ~ The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not beat for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system

A ~ The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.

The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

A ~ The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical situation.

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the client's bed. d. Tell the client everything possible is being done.

A ~ The nurses presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the clients blood pressure. Using all four side-rails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client's safety. Telling a confused client that everything is being done is not the most helpful response.

A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain universal donor blood. d. Prepare the client for emergency surgery.

A ~ The nurses priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery.

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

A ~ This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a. Blood cultures b. Chest x-ray c. Foley insertion d. Serum electrolytes

A ~ Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.

29. A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply. A) Anaphylactic B) Hypovolemic C) Cardiogenic D) Septic E) Neurogenic

A) Anaphylactic D) Septic E) Neurogenic The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of circulatory shock.

39. A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patient's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. A) Blood urea nitrogen (BUN) level B) Urine specific gravity C) Alkaline phosphatase level D) Creatinine level

A) Blood urea nitrogen (BUN) level B) Urine specific gravity D) Creatinine level Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acidbase imbalances, and a loss of the renalhormonal regulation of BP. Urine specific gravity is also affected. Alkaline phosphatase and albumin levels are related to hepatic function.

37. A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patient's care? A) Communicate clearly and frequently with the patient's family. B) Taper down interventions slowly when the prognosis worsens. C) Transfer the patient to a subacute unit when recovery appears unlikely. D) Ask the patient's family how they would prefer treatment to proceed.

A) Communicate clearly and frequently with the patient's family. As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the patient's care, for the family to see, touch, and talk to the patient. The onus should not be placed on the family to guide care, however. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The patient would not be transferred to a subacute unit.

22. The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply. A) Drop in systolic blood pressure of ³40 mm Hg from baselines B) Hypotension that responds to bolus fluid resuscitation C) Exaggerated response to vasoactive medications D) Serum lactate >4 mmol/L E) Mean arterial pressure (MAP) of ˂65 mm Hg

A) Drop in systolic blood pressure of ³40 mm Hg from baselines D) Serum lactate >4 mmol/L E) Mean arterial pressure (MAP) of ˂65 mm Hg Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or mean arterial pressure (MAP) <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted.

The nurse in the ED is caring for a patient recently admitted with a likely myocardial infarction. The nurse understands that the patient's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? A) Dysrhythmias B) Increase in blood pressure C) Increase in heart rate D) Decrease in oxygen demands

A) Dysrhythmias Cardiogenic shock occurs when the heart's ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. Symptoms of cardiogenic shock include angina pain and dysrhythmias. Cardiogenic shock does not cause increased blood pressure, increased heart rate, or a decrease in oxygen demands.

2. In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances? A) Fluid volume circulating in the blood vessels decreases. B) There is an uncontrolled increase in cardiac output. C) Blood pressure regulation becomes irregular. D) The patient experiences tachycardia and a bounding pulse.

A) Fluid volume circulating in the blood vessels decreases. Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.

14. The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? A) Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient education C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema D) Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions

A) Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). 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 should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the patient's response. Reviewing medications, performing a focused cardiovascular assessment, and providing patient education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema are not the priorities for administration of IV vasoactive drugs. Vital signs are taken on a frequent basis when monitoring administration of IV vasoactive drugs, vasoactive medications should be administered through a central venous line, and early discharge instructions would be inappropriate in this time of crisis.

13. You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient? A) Hypothermia B) Bradycardia C) Coffee ground emesis D) Pain

A) Hypothermia Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the patient for cardiovascular overload and pulmonary edema when large volumes of IV solution are administered. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock.

4. The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? A) Lactated Ringer's B) Albumin C) Dextran D) 3% NaCl

A) Lactated Ringer's Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer's and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic.

38. A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patient's plan of care while the patient is ventilated? A) Performing frequent oral care B) Maintaining the patient in a supine position C) Suctioning the patient every 15 minutes unless contraindicated D) Administering prophylactic antibiotics, as ordered

A) Performing frequent oral care Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.

16. The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? A) Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock. B) Inform the patient's family immediately that the patient will likely not survive to allow the family time to make plans and move forward. C) Closely monitor fluid replacement therapy, and inform the family that the patient will probably survive and return to normal life. D) Protect the patient's airway, optimize intravascular volume, and initiate the early rehabilitation process.

A) Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock. The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Informing the patient's family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of-life issues.

26. The ICU nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) due to shock. What nursing action should be prioritized at this point during care? A) Providing information and support to family members B) Preparing the family for a long recovery process C) Educating the patient regarding the use of supportive fluids D) Facilitating the rehabilitation phase of treatment

A) Providing information and support to family members Providing information and support to family members is a critical role of the nurse. Most patients with MODS do not recover, so the rehabilitation phase of recovery is not a short-term priority. Educating the patient about the use of supportive fluids is not a high priority.

15. The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion? A) The patient is in the compensatory stage of shock. B) The patient is in the progressive stage of shock. C) The patient will stabilize and be released by tomorrow. D) The patient is in the irreversible stage of shock.

A) The patient is in the compensatory stage of shock. In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the patient's chance of survival is low and he will certainly not be released within 24 hours. If the patient were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.

33. The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way? A) Through a central venous line B) By a gravity infusion IV set C) By IV push for rapid onset of action D) Mixed with parenteral feedings to balance osmosis

A) Through a central venous line Whenever possible, 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 or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (SATA) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

A, B, C, D ~ Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (SATA) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

A, B, E ~ Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (SATA) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

A, C ~ The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (SATA) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

A, C, D, E ~ Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.

The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (SATA) a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output

A, C, F ~ The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response does not assess perfusion. Respirations do not assess perfusion.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (SATA) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

A, D, E ~ The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

A client has been admitted with a massive MI. In the ED his VS were BP 160/90, SPO2 90% on 2L oxygen. Two hours after admission, the client's BP is 98/50, HR 96, RR 24, SPO2 86% on 2L of oxygen. Which of the following orders for this client would the nurse question? A. Administer normal saline a 200 mL/hr B. Administer morphine 2 mg IV PRN chest pain C. Increase oxygen to 6L per mask D. Monitor urine output hourly

A. Administer normal saline a 200 mL/hr

The nursing assistant reports concerns about the postoperative client who has BP 90/60, HR 80, R 22. What should the RN do? A. Compare these VS with last several readings B. Request that the surgeon come see the client C. Increase the rate of IV fluids D. Reassess VS using different equipment

A. 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 client. 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.

The client with which problem is at highest risk for hypovolemic shock? A. Esophageal varices B. Kidney failure C. Arthritis and daily acetaminophen use D. Kidney stone

A. Esophageal varices Esophageal varices are caused by portal hypertension; the portal vessels are under high pressure and are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen, not acetaminophen, predispose the client to gastrointestinal bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss or hypovolemia.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin when the client is not a diabetic. What response by the nurse is best? A. High glucose is common in shock and needs to be treated B. The stress of this illness has made your spouse diabetic C. The IV solution has lot's of glucose which raises blood sugar. D. Some of the medications we are giving are to raise blood sugar.

A. High glucose is common in shock and needs to be treated

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which of the following would cause the nurse to suspect that the client has early shock? A. Hypotension B. Bradypnea C. Irregular heart rhythm D. Tachycardia

A. Hypotension

Negative pressure rooms

Confirmed COVID19 pts should be placed in negative pressure rooms Isolation technique and ventilation system Prevents contaminated air flow from inside the room to escape outside the room

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? A. Report chest heaviness B. Pedal pulses 1+/4+ bilaterally C. Blood pressure 98/68 mmHg D. Urine output of 32 mL/hr

A. Report chest heaviness

A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? A. Temperature B. Pulse C. Respiration D. Blood pressure

A. Temperature A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.

Which clients are at immediate risk for hypovolemic shock? (Select all that apply.) A. Unrestrained client in motor vehicle accident B. Construction worker C. Athlete D. Surgical intensive care client E. 85-year-old with gastrointestinal virus

A. Unrestrained client in motor vehicle accident D. Surgical intensive care client E. 85-year-old with gastrointestinal virus The client who is unrestrained in a motor vehicle accident is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock; a gastrointestinal virus results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock; they may be at risk for dehydration.

Which change in the client with hypovolemic shock indicates to the nurse that treatment is effective? A. Urine output increases from 5mL/hr to 25mL/hr B. Pulse pressure decreases from 35mmHg to 28mmHg C. Respiratory rate increases from 22/minute to 26/minute D. Body temperature increases from 98.2F to 98.8F

A. Urine output increases from 5mL/hr to 25mL/hr We want the urine output to increase

The intensive care nurse is educating the spouse of a client who is being treated for shock. The spouse states, "The doctor said she has shock. What is that?" What is the nurse's best response? a. "Shock occurs when oxygen to the body's tissues and organs is impaired." b. "Shock is a serious condition, but it is not a life-threatening emergency." c. "Shock progresses slowly and can be stopped by the body's normal compensation." d. "Shock is a condition that affects only specific body organs like the kidneys."

A: Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency. Shock represents the "whole-body response," affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal of the cause of shock, resulting in death.

A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first? a. Obtain two sets of blood cultures. b. Administer the prescribed IV vancomycin (Vancocin). c. Obtain central venous pressure (CVP) measurements. d. Administer the prescribed IV norepinephrine (Levophed).

A: Blood cultures should be obtained before IV antibiotics are started. If hypotension occurs, fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if hypotension persists.

The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock? a. Severe head injury from a motor vehicle accident b. Diabetes insipidus from polycystic kidney disease c. Ischemic cardiomyopathy from severe coronary artery disease d. Vomiting of blood from a gastrointestinal ulcer

A: Distributive shock is the type of shock that occurs when blood volume is not lost from the body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen. Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord injury, or head trauma. The other clients are at risk for hypovolemic and cardiogenic shock

The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication does the nurse expect to be prescribed? a. Heparin sodium b. Vitamin K c. Corticosteroids d. Hetastarch (Hespan)

A: During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors. The other medications would not be prescribed during the hyperdynamic phase of septic shock.

The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question? a. Enoxaparin (Lovenox) 40 mg subcutaneous twice daily b. Transfusion of 2 units of fresh frozen plasma c. Regular insulin intravenous drip per protocol d. Cefazolin (Ancef) 1 g IV every 6 hours

A: Therapy during the second (late) phase of septic shock is aimed at enhancing the blood's ability to clot. Enoxaparin would increase the client's risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client's blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.

Sepsis Lab Tests

ABGs Initial ABGs may reflect a respiratory alkalosis due to tachypnea Hypercapnia and hypoxia are present as respiratory failure worsens Later stages of shock reveal a metabolic acidosis due to anaerobic metabolism Venous oxygen saturation Decreased SvO2 and ScvO2 are typically indicators of inadequate oxygen delivery In later sepsis, values may be elevated because of maldistribution of blood flow and are not indicative of recovery Metabolic profile Renal failure and liver failure, as evidenced by increased BUN and creatinine levels and liver function test results, may become evident as a result of decreased organ perfusion Lactate Increased lactate level and negative base deficit are evidence of poor perfusion at the cellular level Normalizing levels are an endpoint demonstrating adequate resuscitation Sustained abnormal levels are indicators of increased risk of mortality Clotting studies Decreased levels of fibrinogen, increased fibrin degradation products, increased D-dimer levels (an indicator of clot breakdown), decreased platelets, prolonged prothrombin and activated partial thromboplastin times, and decreased antithrombin III levels indicate the progression to DIC

Hypovolemic Shock Lab Tests

ABGs Initial ABGs may reflect a respiratory alkalosis due to tachypnea Later stages of shock reveal a metabolic acidosis due to anaerobic metabolism Venous Oxygen Saturation SvO2/ScvO2 - Decreased oxygen saturation is an indicator of inadequate oxygen delivery HgB and HcT Hemoglobin and hematocrit values may be decreased if the cause of hypovolemic shock is bleeding. Metabolic profile Renal failure and liver failure, as evidenced by increased BUN and creatinine levels and liver function test results, may become evident as a result of decreased organ perfusion Lactate Increased lactate level and negative base deficit are evidence of poor perfusion at the cellular level. Decreasing lactate level is an endpoint demonstrating adequate resuscitation

Lab tests for cardiogenic shock

ABGs Initial ABGs may reflect a respiratory alkalosis due to tachypnea Later stages of shock reveal a metabolic acidosis due to anaerobic metabolism. Venous oxygen saturation Decreased SvO2/ScvO2 is an indicator of inadequate DO2 Metabolic profile Renal failure and liver failure as evidenced by increased BUN and creatinine levels and liver function test results may become evident because of decreased organ perfusion Lactate Increased lactate level and negative base deficit are evidence of poor perfusion at the cellular level Decreasing lactate levels are an endpoint demonstrating adequate resuscitation

Things to Remember about shock

All types are caused by decreased cardiac output causing a decrease in tissue perfusion ALWAYS give fluid BEFORE giving vasopressors; Need fluid to push through vessels; can lead to necrotic tissue if vasopressor is given before fluid; Fingers and toes go necrotic first; give pressors through a central line (may start in P IV until they can place a central line) Vasopressors shunt blood from periphery to the vital organs; assess urinary output to know if organs are being perfused properly

Pneumonia clinical manifestations

Altered mental status Respiratory rate >30 Hypotension Heart rate >125 Body temperature <35C or >40C Arterial blood pH <7.35 Serum Na level <130 HCT <30% PaO2 <60mmHg on >40% supplemental O2 Pleural effusion on CXR or CT scan

The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient's diagnosis?

Alveolar macrophages

Endocrine compensation of shock

After a drop in blood pressure, the kidneys respond by releasing the enzyme renin. Renin reacts with angiotensinogen to create angiotensin I Angiotensin I is then converted in the lungs to angiotensin II via angiotensin-converting enzyme Angiotensin II is a potent vasoconstrictor that increases blood pressure; Angiotensin II also acts on the adrenals to release aldosterone The release of aldosterone promotes sodium and water reabsorption in the kidneys, which increases the circulating fluid volume. Also in an effort to increase the circulating volume, antidiuretic hormone is released by the posterior pituitary in response to decreased blood volume Acts on the kidney to conserve water.

Obstructive Shock Risk Factors

Extracardiac disorders that impair ventricular filling Acute PE Impaired cardiac empyting Cardiac tamponade Tension pneumothorax

Sepsis bundle of care Antibiotics

Administered within 1 hr upon arrival Prompt ID and treatment of the organism can decrease morality Cultures done before administration Cultures should be done before antibiotics are administered

Sepsis bundle of care Corticosteroid therapy

Adrenal insufficiency is sometimes a feature of sepsis, but the use of steroids in treatment is not routinely recommended The Surviving Sepsis guidelines recommend low-dose steroids only if the patient has not been responsive to fluid and vasopressor therapy

COVID Complications

ARDS Cytokine-mediated inflammatory response DVT and PE Arrythmias Cardiomyopathy

Sepsis bundle of care Hour 1

Activities that need to be completed within 1 hr after identifying sepsis Treatment may not be completed in 1 hr Treatment should begin immediately

Hypovolemic shock causes

Acute blood loss Trauma, GI bleed Rapid fluid loss Vomiting, diarrhea, burns

Hypovolemic shock pathophysiology

Acute loss of volume Blood or fluid Decrease venous return Decrease stroke volume and CO Decreased tissue perfusion

Neurogenic Shock nursing Actions

Administer IV fluids as ordered Cautious fluid resuscitation is provided to increase vascular volume to match the increase in the size of the vascular space due to the massive dilation Administer IV medications as ordered Vasoactive drips Administration of vasoactive drips aids in increasing vasomotor tone and systemic vascular resistance. Atropine Atropine is used for the treatment of bradycardia to block the action of the vagus nerve in the parasympathetic nervous system, increasing the HR. Prepare for pacing Pacing may be necessary to treat recurrent episodes of bradycardia Raise head of bed slowly Because of loss of systemic vasomotor tone, patients in neurogenic shock are particularly vulnerable to orthostatic hypotension. Apply venous thromboembolism prophylaxis Sequential compression devices or medication such as heparin Patients in neurogenic shock are at high risk for venous thromboembolism, particularly in cases where the etiology of neurogenic shock is spinal cord injury

The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse implement to attain the goal of normal body temperature?

Administer antipyretic medications

Pneumonia Nursing Actions

Administer humidified oxygen as ordered Maintain adequate oxygen levels Administer medications as ordered Antibiotics Pulmonary hygiene Incentive spirometry Coughing and deep breathings Postural drainage Vibration/percussion Early mobility Helps mobilize secretions Patient positioning Elevate HOB 30 degrees prevents aspiration of secretions Side to side turning assists with alveolar recruitment Monitor I&O Assists with thinning secretions Ensure adequate nutritional support Adequate intake is necessary for cell recovery Small frequent meals that are high in protein and vitamins are recommended Activity Approach activities of care with intervals of rest Fatigued and decreased tissue oxygen delivery limit activity tolerance

A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease. Which nursing intervention is most appropriate for this patient?

Administer the medication on an empty stomach

Progressive stages of shock

Failure of compensatory mechanisms Extensive shunting of blood vital organs Profound hypoperfusion Worsening metabolic acidosis Respiratory acidosis

The nurse monitors for which clinical manifestations in the patient in compensatory shock? A. Blood pressure within normal limits, oliguria B. Cold extremities, hyperglycemia C. Weak pulses, hypoventilation D. Hypotension, tachycardia

Answer: A Rationale: Clinical manifestations for compensatory shock include: Restlessness, confusion, increased heart rate, tachypnea, respiratory alkalosis, oliguria, hyper- glycemia, decreased bowel sounds, weak pulses, and cool, moist skin. Compensatory mechanisms may temporarily maintain a normal blood pressure. Cold extremities and hypotension are associated with progressive shock.

After receiving the change of shift report, which of the following patients should the nurse assess first? A. 75-year-old client admitted after a myocardial infarction who is noted to be confused B. 70-year-old type 2 diabetic client with a history of mitral valve prolapse who is scheduled to receive IV antibiotics C. 60-year-old woman with a pacemaker who has a HR of 64 bpm and is requesting assistance to the bathroom D. 45-year-old woman scheduled for a thallium scan who is receiving warfarin (Coumadin) for atrial fibrillation

Answer: A Rationale: Confusion in a patient after myocardial infarction may be the first indicator of decreased cardiac output's and the beginnings of cardiogenic shock.

In a patient without a central line, which clinical finding does the nurse look for to indicate effective response to treatment in the initial stage of shock? A. Increased urine output B. Increased HR C. Decreased bowel sounds D. Decreased blood pressure

Answer: A Rationale: Increased urine output indicates fluid volume status is normalizing. Tachycardia indicates the body is still compensating for inadequate cardiac output. Decreased blood pressure and bowel sounds both indicate shock is continuing.

The nurse understands that __________________ increases as the delivery of oxygen to the tissues falls below the tissues' requirements. (Select all that apply.) A. VO2 B. Oxygen debt C. SvO2 D. PaO2 E. Preload

Answer: A and B Rationale: Shock is described as an imbalance between oxygen delivery and oxygen demand. Mixed venous oxygen saturation and PaO2 would decrease as oxygen delivery decreases. Decreasing preload and contractility are causes of inadequate oxygen delivery. Oxygen con- sumption, normally stable at the tissue level, would in- crease in an attempt to meet needs as delivery decreases causing an oxygen debt.

The nurse understands that the following are the best parameters for evaluating the severity of the shock state: (Select all that apply.) A. SvO2 B. Lactate level C. Base excess D. Glucose level E. PaO2

Answer: A, B, and C Rationale: SvO2 is a reflection of oxygen consump- tion at the tissue level. Lactate and base excess estimates the extent of acidosis at the tissue level. Evidence has shown all three are good indicators of the severity of shock. Systemic vascular resistance is either up or down depending upon the type of shock or compensation. Glucose levels may elevate as part of the compensatory process but don't directly reflect severity. Changes in PaO2 reflect the severity of pulmonary disease, not shock.

The nurse understands which hemodynamic parameters are consistent with hypovolemic shock? A. Decreased cardiac output, decreased systemic vascular resistance, decreased right atrial pressure B. Decreased cardiac output, increased systemic vascular resistance, decreased right atrial pressure C. Decreased cardiac output, increased systemic vascular resistance, increased right atrial pressure D. Decreased cardiac output, decreased systemic vascular resistance, increased right atrial pressure

Answer: B Rationale: Hypovolemic shock results in a decreased cardiac output due to decreased filling pressures. Sys- temic vascular resistance increases as a compensatory mechanism.

What is one clinical manifestation of obstructive shock? A. Increased urine output B. Muffled breath sounds C. Decreased appetite D. Hyperactive bowel sounds

Answer: B Rationale: Muffled breath sounds may indicate tension pneumothorax.

The nurse has just received report on assigned patients. Which of the following patients should be assessed first? A. The postoperative patient complaining of pain B. The postoperative patient who is noted to have a decreased urine output C. The preoperative patient being readied for the operating room D. The preoperative patient requiring antibiotics prior to the procedure

Answer: B Rationale: Postoperative patient with a decreased urine output is showing signs of sepsis. Prompt intervention is essential to prevent deterioration along the sepsis continuum.

The nurse understands that the following indicates the initial phase of DIC: A. Bleeding from all puncture sites B. Cold, mottled extremities C. Increased antithrombin III levels D. Increased fibrin degradation products

Answer: B Rationale: The initial phase of DIC is characterized by enhanced clotting obstructing flow causing cold mottled extremities. One reason for the enhanced clotting is decreased anti-thrombin III levels. The second phase of DIC is characterized by excessive bleeding due to clot breakdown resulting in increased fibrin degradation products.

What is the third stage of shock? A. Primary stage B. Progressive stage C. Tertiary stage D. Refractory stage

Answer: B Rationale: The progressive stage is the third stage of shock

The nurse understands that which patient is at risk of developing hypovolemic shock? A. A patient with severe valvular disease B. A patient undergoing surgery with spinal anesthesia C. A patient with severe GI distress D. A patient with a large pneumothorax status post a motor vehicle crash

Answer: C Rationale: Hypovolemic shock can be caused by the fluid loss associated with excessive vomiting or diarrhea. A large pneumothorax may progress to a tension pneumothorax. Both severe valvular disease and tension pneumothorax may cause obstructive shock. Complications associated with spinal anesthesia may cause neurogenic shock.

The nurse correlates which of the following hemodynamic parameters to the patient with cardiogenic shock? A. Decreased afterload B. Increased contractility C. Increased cardiac output D. Increased right atrial pressure

Answer: D Rationale: Cardiogenic shock is caused by decreased contractility which results in a decreased cardiac output in the face of adequate or increased filling pressures. In an attempt to increase cardiac output and blood pressure, vasoconstriction occurs as a compensatory mechanism increasing afterload.

What is the second step in the sepsis continuum? A. Multiple organ dysfunction syndrome (MODS) B. Sepsis C. Septic shock D. Systemic inflammatory response syndrome (SIRS)

Answer: D Rationale: SIRS is the second step in the sepsis continuum. Infection is the first step, then SIRS, then sepsis, septic shock leading to MODS

The nurse understands the following are clinical manifestations of neurogenic shock. (Select all that apply.) A. Tachycardia B. Vasoconstriction C. Tachypnea D. Decreased right atrial pressure E. Bradycardia

Answer: D and E Rationale: Neurogenic shock is caused by vasodilata- tion resulting in decreased venous return and filling pressures. Due to the loss of the sympathetic response, bradycardia occurs. Respiratory rate may be low due to the injury causing neurogenic shock such as cervical spinal cord injury.

COVID Medications

Antipyretics Anticoagulants Pulmonary vasodilators Glucocorticoids Antiviral Monoclonal antibody therapy Convalescent plasma IL-6 Antimalarial Vaccines

HIV Symptomatic chronic infection

As CD4 count continues to fall, control over viral infection is slowly lost Immune system becomes less able to fight off infection Nonspecific symptoms Frequent respiratory tract infection Skin problems Lymphadenopathy (large lymphnodes) Weight loss

Classification of COVID patients

Asymptomatic COVID nucleic acid test positive Without any clinical symptoms and signs Normal chest imaging Mild Symptoms of acute upper respiratory tract infection Fever, myalgia, cough, sore throat, runny nose, sneezing Digestive symptoms N/V Abd pain Diarrhea Moderate Pneumonia Frequent fever, cough No obvious hypoxemia CT shows legions Severe Pneumonia with hypoxemia (SpO2 <92%) Critical ARDS May also have Shock Encephalopathy Myocardial injury Heart failure Coagulation dysfunction AKI

HIV Nursing Teaching Topics

Avoidance of high risk behaviors that increase risk of transmission Use condoms during sex Avoid use of street drugs or alcohol Adherence to treatment regimen Essential in managing progression of the disease Take medications at the same time each day Understand what each medication does Implementing infection control precautions at home Discuss specific infection control measures Clean blood spills with bleach Avoid raw or undercooked eggs, meat, poultry, or fish to reduce risk of diarrhea illness Avoid cat litter Signs and symptoms of report to the HCP urgently

A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

B ~ Lower blood volume will decrease MAP. The other answers are not accurate.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

B ~ A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm3 is slightly high but is not as critical as the lactate level.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

B ~ Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. All my friends and neighbors are planning a party for me. b. I hope I can get my water turned back on when I get home. c. I am going to have my daughter scoop the cat litter box. d. My grandkids are so excited to have me coming home!

B ~ All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.

B ~ Assessed vital signs and hemodynamic values indicate decreased circulating volume. The patient has not responded appropriately to therapy aimed at increasing circulating volume. Additional intervention is needed because response to therapy is not appropriate, values are abnormal, and timely intervention is critical for a patient with low circulating blood volume.

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? a. Blood transfusion with packed red blood cells is required. b. Hemoglobin and hematocrit results indicate hemodilution. c. Fluid resuscitation has resulted in fluid volume overload. d. Fluid resuscitation has resulted in third spacing of fluid.

B ~ Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins. Hemoglobin and hematocrit results indicate hemodilution. Given the clinical scenario, there is no evidence to support the need for a blood transfusion and no evidence of fluid overload. Although administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third spacing of fluid, this fact does not support the hemoglobin and hematocrit results.

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

B ~ Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

B ~ Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn't give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the client's tissue perfusion further. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.

B ~ Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.

The nurse is administering intravenous norepinephrine (Levophed) at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse? a. Blood pressure 100/60 mm Hg b. Swelling at the IV site c. Heart rate of 110 beats/min d. Central venous pressure (CVP) of 8 mm Hg

B ~ Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine (Levophed) through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse. A blood pressure of 100/60 mm Hg, heart rate of 110 beats/min, and a CVP of 8 mm Hg are adequate and do not require immediate intervention.

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm-5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a. Furosemide (Lasix) 20 mg intravenous (IV) every 4 hours as needed for CVP > 20 mm Hg b. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain c. Dobutamine (Dobutrex) infusion at a rate of 2-20 mcg/kg/min as needed for CI < 2 L/min/m2 d. Dopamine (Intropin) infusion at a rate of 5-10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

B ~ The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order options.

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? a. Diphenhydramine (Benadryl) 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone (Solu-Medrol) 125 mg intravenously d. Ranitidine (Zantac) 50 mg intravenously

B ~ The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine (Benadryl) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone (Solu-Medrol), are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine (Zantac) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

B ~ Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? a. Administer acetaminophen (Tylenol) 650-mg suppository prn every 6 hours for pain. b. Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic. c. Complete neurological assessment every 4 hours for the next 24 hours. d. Administer furosemide (Lasix) 20 mg IV every 4 hours for a CVP > 20 mm Hg.

B ~ Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit. The nurse should question the use of the dopamine (Intropin) infusion. All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

30. A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boy's mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock? A) Rapid onset of acute hypertension B) Rapid onset of respiratory distress C) Rapid onset of neurologic compensation D) Rapid onset of cardiac arrest

B) Rapid onset of respiratory distress Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur if prompt treatment is not provided.

8. The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on what intervention? A) Reviewing the cause of shock and prioritizing the patient's psychosocial needs B) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C) Giving the prescribed treatment, but shifting focus to providing family time as the patient is unlikely to survive D) Promoting the patient's coping skills in an effort to better deal with the physiologic changes accompanying shock

B) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.

23. An adult patient has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this patient. What aspect of his care should be prioritized by the home health nurse? A) Providing supervision to home health aides in providing necessary patient care B) Assisting the patient and family to identify and mobilize community resources C) Providing ongoing medical care during the family's rehabilitation phase D) Reinforcing the importance of continuous assessment with the family

B) Assisting the patient and family to identify and mobilize community resources The home care nurse reinforces the importance of continuing medical care and helps the patient and family identify and mobilize community resources. The home health nurse is part of a team that provides patient care in the home. The nurse does not directly supervise home health aides. The nurse provides nursing care to both the patient and family, not just the family. The nurse performs continuous and ongoing assessment of the patient; he or she does not just reinforce the importance of that assessment.

1.A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.

B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.

27. A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply. A) Hypovolemia B) Difficulty breathing C) Cardiovascular overload D) Pulmonary edema E) Hypoglycemia

B) Difficulty breathing C) Cardiovascular overload D) Pulmonary edema Fluid replacement complications can occur, often when large volumes are administered rapidly. Therefore, the nurse monitors the patient closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement.

36. An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a really bad allergic reaction to peanuts after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize? A) Establishing central venous access and beginning fluid resuscitation B) Establishing a patent airway and beginning cardiopulmonary resuscitation C) Establishing peripheral IV access and administering IV epinephrine D) Performing a comprehensive assessment and initiating rapid fluid replacement

B) Establishing a patent airway and beginning cardiopulmonary resuscitation If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. As well, a patent airway is an immediate priority. Epinephrine is not withheld pending IV access and fluid resuscitation is not a priority.

The nurse in the ICU is caring for a 47-year-old, obese male patient who is in shock following a motor vehicle accident. The nurse is aware that patients in shock possess excess energy requirements. What would be the main challenge in meeting this patient's elevated energy requirements during prolonged rehabilitation? A) Loss of adipose tissue B) Loss of skeletal muscle C) Inability to convert adipose tissue to energy D) Inability to maintain normal body mass

B) Loss of skeletal muscle Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the patient's recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, and the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this patient.

6. A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing? A) Anaphylactic shock B) Neurogenic shock C) Septic shock D) Hypovolemic shock

B) Neurogenic shock Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

5. A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? A) The drug should be discontinued immediately after blood pressure increases. B) The drug dose should be tapered down once vital signs improve. C) The patient should have arterial blood gases drawn every 10 minutes during treatment. D) The infusion rate should be titrated according the patient's subjective sensation of adequate perfusion.

B) The drug dose should be tapered down once vital signs improve. When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but every10-minute draws are not the norm.

15 minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102 F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (SATA) a. Administer acetaminophen (Tylenol). b. Document the patient's response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the physician. f. Stop the transfusion.

B, D, E, F ~ In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction, interventions used, and patient response to treatment are documented. Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the infusion further increases the likelihood of worsening the transfusion reaction.

The nurse is providing discharge teaching to the post-operative client. Which statement by the client indicates need for more teaching? A. "I must call the doctor if I develop a fever." B. "I will call my provider if I have any pain." C. "If the dressing gets soaked with bright red blood I will call the doctor." D. "If the incision is red and swollen, I will call the provider."

B. "I will call my provider if I have any pain."

Which of the following would indicate a positive outcome after starting dopamine (Intropin)? A. Hourly urine output of 10-18 mL B. BP 90/60 and MAP 70 C. Blood glucose 245 D. Serum creatinine 3.6mg/dL

B. BP 90/60 and MAP 70 Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response in this case. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and are a negative consequence of shock, not a positive response. Although a blood glucose of 245 mg/dL is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? A. Client receiving a blood transfusion B. Client with severe ascites C. Client with myocardial infarction D. Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

B. Client with severe ascites Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

Which laboratory result is seen in late sepsis? A. Decreased serum lactate B. Decreased segmented neutrophil count C. Increased numbers of monocytes D. Increased platelet count

B. 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 due to consumptive coagulopathy.

The nurse plans to administer an antibiotic to the client newly admitted with septic shock. Which of the following is the most appropriate action for the nurse to take first? A. Administer the antibiotic immediately B. Ensure that blood cultures were drawn C. Obtain signature for informed consent D. Take the client's vital signs

B. Ensure that blood cultures were drawn Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours; timing is essential.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? A. Obtain consent for emergency surgery B. Ensure the client has a patent airway C. Apply direct pressure to the dressing D. Start two large bore IV catheters

B. Ensure the client has a patent airway

How does the nurse recognize that the client with septic shock has severe tissue hypoxia? A. PaCO2 58mm Hg B. Lactate level 9.0mmol/L C. INR 1.6 D. Potassium 2.8mEq/mL

B. Lactate level 9.0mmol/L

A postoperative client is admitted to the ICU with hypovolemic shock. Which nursing action should the nurse delegate to the experienced nursing assistant? A. Obtain vital signs every 15 minutes B. Measure hourly urine output C. Check oxygen saturation D. Assess level of alertness

B. Measure hourly urine output Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

A client brought to the emergency department after a motorcycle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the initial stage of hypovolemic shock? A. When was the last time you urinated B. What is your usual heart rate? C. Are you more thirsty that normal? D. Is your skin usually cool and pale?

B. What is your usual heart rate?

A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer? a. Normal saline b. Ringer's lactate c. 5% dextrose in water d. 5% dextrose in 0.45% normal saline

B: Ringer's lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as a buffer in the presence of acidosis. The other solutions do not contain any substance that would buffer or correct the client's acidosis.

The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. Which nursing intervention is a priority when administering this medication? a. Ask if the client has chest pain every 30 minutes. b. Assess the client's blood pressure every 15 minutes. c. Monitor the client's urinary output every hour. d. Observe the client's extremities every 4 hours.

B: The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and can increase shock. The nurse should monitor the client's pain, urinary output, and extremities, but these assessments do not directly relate to the nitroprusside infusion.

The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates that the client is at risk for acidosis? a. Decreased serum creatinine b. Increased serum lactic acid c. Increased urine specific gravity d. Decreased partial pressure of arterial carbon dioxide

B: The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus some cells are metabolizing anaerobically. Such metabolism increases the production of lactic acid, resulting in an increase in hydrogen ion production and acidosis. Other laboratory values associated with acidosis include increased creatinine (impaired renal function) and increased partial pressure of arterial carbon dioxide. Urine specific gravity is not associated with acidosis.

Hypovolemic Shock Physiologic Response

Body does not have enough fluid to perfuse to organs; MODS

Pneumonia Medications

Bronchodilators Albuterol (Short acting selective b2 adreno agonist) Combivent (slow onset cholinergic) Aerosol nebulization or metered dose inhaler Antibiotics Based on organisms Broad spectrum initially

The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this diagnosis?

Hemoptysis

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

C ~ Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client's previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex). The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? a. Obtain a stat serum potassium level. b. Order a stat 12-lead electrocardiogram. c. Reduce the rate of dobutamine (Dobutrex). d. Assess the patient's hourly urine output.

C ~ Dobutamine (Dobutrex) is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states improving overall cardiac performance. The patients cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart. There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram. Assessment of hourly urine output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario.

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102 F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids

C ~ Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6 F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patient's heart rate.

C ~ Given the acute nature of the patient's blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient's blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8 F. Which intervention is most important for the nurse to include in the patients plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)

C ~ Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patients oxygen saturation is 95% on room air with an adequate respiratory rate. The application of 100% oxygen via facemask is not indicated. The patients heart rate is adequate to support a normal blood pressure.

The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? a. Administer pain medication. b. Turn patient every 2 hours. c. Assess core body temperature. d. Apply bilateral heel protectors.

C ~ Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body temperature is a priority. While administration of pain management, repositioning the patient every 2 hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario.

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a. Frequent turning b. Monitoring intake and output c. Enteral feedings d. Pain management

C ~ Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa. Monitoring intake and output, frequent turning, and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission.

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable (smart) IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

C ~ Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a smart pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.

The nurse is providing care for a patient who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states? A) Third spacing of fluid B) Dysrhythmias C) Tachycardia D) Gastric hypermotility

C) Tachycardia Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms.

A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer's bolus d. Packed red blood cells

C ~ The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.

C ~ This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.

34. The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the patient? A) Anaphylaxis B) Decreased oxygen consumption C) Abdominal compartment syndrome D) Decreased serum osmolality

C) Abdominal compartment syndrome Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are administered. The scenario does not describe an antigenantibody reaction of any type. Decreased oxygen consumption by the body is not a concern in hypovolemic shock. With a decrease in fluids in the intravascular space, increased serum osmolality would occur.

31. The ICU nurse is caring for a patient in neurogenic shock following an overdose of antianxiety medication. When assessing this patient, the nurse should recognize what characteristic of neurogenic shock? A) Hypertension B) Cool, moist skin C) Bradycardia D) Signs of sympathetic stimulation

C) Bradycardia In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, 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.

The acute care nurse is providing care for an adult patient who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock? A) Increased hunger B) Decreased thirst C) Decreased urinary output D) Increased capillary perfusion

C) Decreased urinary output During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.

24. A critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock? A) Aggressive hypoglycemic control B) Administration of hypertonic IV fluids C) Early provision of nutritional support D) Aggressive antibiotic therapy

C) Early provision of nutritional support Nutritional support is necessary for all patients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many patients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in patients with septic shock.

10. The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions? A) Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B) Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months C) Promoting communication with the patient and family along with addressing end-of-life issues D) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

C) Promoting communication with the patient and family along with addressing end-of-life issues Promoting communication with the patient and family is a critical role of the nurse with a patient in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the patient's wishes. Many cases of MODS result in death and the life expectancy of patients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the patient.

12. The nurse is caring for a patient whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock? A) Elevated systolic blood pressure B) Elevated mean arterial pressure (MAP) C) Shallow, rapid respirations D) Bradycardia

C) Shallow, rapid respirations A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.

7. The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patient's nutritional needs. What physiologic process contributes to these increased nutritional needs? A) The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate (ATP) B) The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements D) The increase in GI peristalsis during shock and the resulting diarrhea

C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.

17. The nurse in a rural nursing outpost has just been notified that she will be receiving a patient in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. You know that the best choice for fluid replacement for this patient is what? A) 5% albumin because it is inexpensive and is always readily available B) Dextran because it increases intravascular volume and counteracts coagulopathy C) Whatever fluid is most readily available in the clinic, due to the nature of the emergency D) Lactated Ringer's solution because it increases volume, buffers acidosis, and is the best choice for patients with liver failure

C) Whatever fluid is most readily available in the clinic, due to the nature of the emergency The best fluid to treat shock remains controversial. In emergencies, the best fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids can be administered to restore intravascular volume. There is no consensus regarding whether crystalloids or colloids, such as dextran and albumin, should be used; however, with crystalloids, more fluid is necessary to restore intravascular volume. Albumin is very expensive and is a blood product so it is not always readily available for use. Dextran does increase intravascular volume, but it increases the risk for coagulopathy. Lactated Ringer's is a good solution choice because it increases volume and buffers acidosis, but it should not be used in patients with liver failure because the liver is unable to covert lactate to bicarbonate.

Which manifestations of shock are a result of compensatory mechanisms to maintain circulating blood volume? A) Edema and weight gain B) Confusion and lethargy C) Decreased urine output and thirst D) Increased pulse and respiratory rates

C) Decreased urine output and thirst Rationale: Both reduced urine output and thirst are stimulated by a decreasing circulating blood volume. When people can respond to thirst by drinking, the action compensates temporarily by increasing circulating fluid volume. Decreased or absent urine output compensates by preventing a greater fluid loss. The fluid that would have been lost from the body as urine is retained. This is why hourly urine output measurements are such a sensitive indicator for whether shock is improving or progressing. Edema and weight gain are not compensations for circulating blood volume. Confusion and lethargy are responses to circulating blood volume, not compensation to improve it. Increasing pulse and respiratory rates compensate for hypoxia, not for reduced volume.

The nurse is caring for a group of clients at risk for sepsis. Which of the following puts the client at highest risk? A. Pernicious anemia B. Pericarditis C. Post-kidney transplant D. Client owns an iguana

C. Post-kidney transplant

How does the nurse recognize that the client is in early stages of septic shock? A. Pallor and cool skin B. Blood pressure 84/50 C. Tachypnea & tachycardia D. Respiratory acidosis

C. Tachypnea & tachycardia

The nurse is assessing clients in the emergency department. Which client is at highest risk for developing septic shock? a. 25-year-old man who has irritable bowel syndrome b. 37-year-old woman who is 20% above ideal body weight c. 68-year-old woman who is being treated with chemotherapy d. 82-year-old man taking beta blockers for hypertension

C: Certain conditions or treatments that cause immune suppression, such as having cancer and being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a person to septic shock. The other client situations do not increase the client's risk for septic shock.

The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin) drip. Which manifestation is a desired response to this medication? a. Decrease in blood pressure b. Increase in heart rate c. Increase in cardiac output d. Decrease in mean arterial pressure

C: Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation. Tachycardia is not a desired response but often occurs as a side effect.

The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what is the priority intervention for this client? a. Administer an aminoglycoside. b. Initiate a dopamine hydrochloride (Intropin) drip. c. Administer crystalloid fluids. d. Initiate an intravenous heparin drip.

C: IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids. Aminoglycosides and heparin are given to clients with septic shock.

The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which important action related to the administration of this drug does the nurse implement? a. Assess the client's respiratory rate. b. Administer the medication with gravity tubing. c. Protect the medication from light with an opaque bag. d. Monitor for hypertensive crisis.

C: Sodium nitroprusside (Nipride) must be protected from light to prevent degradation of the drug. It should be delivered via pump. This medication does not have any effect on respiratory rate. Hypertension is a sign of milrinone (Primacor) overdose.

A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock? a. "Are you more thirsty than normal?" b. "When was the last time you urinated?" c. "What is your normal heart rate?" d. "Is your skin usually cool and pale?"

C: The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress. The other questions would not identify early stages of shock.

Cardiogenic Shock Clinical Manifestations

Chest pain Diaphoresis N/V Decreased cardiac output Hypotension Decreased LOC Decreased urine output Weak pulses Cool skin Hypoactive bowel sounds Metabolic acidosis As shock progresses Profound hypotension and bradycardia develop Organ systems begin to fail Laboratory analysis reveals increases in creatinine and liver enzymes, demonstrating renal and liver failure Coma; cyanotic, mottled skin; absent bowel sounds; and anuria are present.

Stages of Shock

Compensatory Progressive Refractory

A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the client's systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first? a. Insert a Foley catheter to monitor urine output closely. b. Ask the client's family to come to the hospital because death is near. c. Initiate the prescribed dobutamine (Dobutrex) intravenous drip. d. Obtain blood cultures before administering the next dose of antibiotics.

C: The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client's pulse pressure is decreasing rapidly. The family should be updated appropriately.

AIDS

CD4 count drops below 200 Opportunistic infections Diagnosis considered with CD4 is less than 200 or when patient is diagnoses with one or more AIDS-defining illnesses

Shock Assessments

CNS Restlessness Confusion Irritability Lethargy Coma CV Hypotension Narrow pulse pressure Tachycardia, then bradycardia Skin color Pale, mottled, cool, cyanotic Peripheral pulses Thready pulses Capillary refill Sluggish capillary refill Respiratory Tachypnea ABGs Pulse ox Renal Oliguria, then anuria Increased creatinine Signs of acute renal failure GI Hypoactive bowel sounds Nausea Vomiting Vulnerable to poor perfusion and ischemia Systemic inflammatory response Precursor to MODS (multiorgan dysfunction syndrome)

Staff PPE

COVID-19 + patients Fitted respirator masks N95 respirator Air purifying respirator Elastomeric respirator Eye protection Face shield Gloves Gown All other patients Surgical maks Face shield Gloves

Septic Shock Physiologic Response

Can be mild if caught early; Complications include DIC from inflammatory response, MODS, death

Cardiogenic shock pathophysiology

Cardiogenic shock is defined as a state of hypoperfusion at the tissue level resulting from severe impairment of ventricular contraction in the presence of adequate vascular volume. As a result of damaged myocardium, there is a marked reduction in contractility, which reduces the ejection fraction (the percentage of blood ejected from the ventricle with each contraction) and cardiac output The result is increased left and right ventricular filling pressures but decreased cardiac output

Obstructive Shock Hemodymanic Parameter

Caused by a blockage of blood flow; massive PE, tension pneumothorax, tamponade Decreased CO; low BP; high HR; high systemic vascular resistance (a lot of pressure)

Obstructive Shock

Caused by a mechanical barrier to ventricular filling or ventricular emptying (increased afterload), causing decreased cardiac output Examples of disorders resulting in impaired filling include cardiac tamponade and tension pneumothorax.

Anaphylactic Shock Hemodymanic Parameter

Caused by an allergic reaction causing massive vasodilation and circulatory collapse Decreased CO; low BP; high HR

Septic Shock Hemodymanic Parameter

Caused by an infection in the blood stream, normally from bacteria compensating; warm temp Late/General: Decreased CO; low BP; high HR; low temp Low CVP (fluid shifts outside of vessels), low systemic vascular resistance; temp >100.4 or temp <96.0; low O2

Neurogenic Shock Hemodymanic Parameter

Caused by any spinal cord injury; Decreased CO; low BP; low HR; low systemic vascular resistance (vasodilation)

The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does the nurse anticipate for this patient?

Cough

TB Treatment

Cure disease Minimize transmission

When caring for client with hypovolemic shock with these assessment findings, T 97.9, P 122, R 24, BP 86/48, total urine output 20mL in last 2 hours, skin cool and clammy, which of the following orders would the nurse question? A. Dopamine (Intropin) 12mcg/kg/min B. Dobutamine (Dobutrex) 5mcg/kg/min C. Plasmanate 1 unit D. Bumetanide (Bumex) 1mg IV

D. Bumetanide (Bumex) 1mg IV A diuretic such as bumetanide will decrease blood volume in a client who is already hypovolemic; this order should be questioned because this is not an appropriate action to expand the client's blood volume. The other orders are appropriate for improving blood pressure in shock, and do not need to be questioned.

During the initial stages of shock, what are the physiological effects of decreased cardiac output? a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation

D ~ A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.

The nurse is administering both crystalloid & colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a. Normal body temperature b. Balanced intake and output c. Adequate pain management d. Urine output of 0.5 mL/kg/hr

D ~ Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output

D ~ As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In the early stages of septic shock, cardiac output is high.

The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18

D ~ As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All other listed arterial blood gas values are within normal limits.

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102 F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures from two sites c. IV antibiotic administration d. Isotonic fluid challenge

D ~ Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario.

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

D ~ Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems.

COVID Assessment and analysis

Patient with COVID can vary greatly in presentation All new respiratory symptoms should be treated as COVID Isolation precautions should be initiated immediately because of high level of infectiousness

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

D ~ Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.

3. The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A) Increased urine output B) Decreased heart rate C) Hyperactive bowel sounds D) Cool, clammy skin

D) Cool, clammy skin In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patient's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

28. When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the pooling of blood in the periphery leads to what pathophysiological effect? A) Increased stroke volume B) Increased cardiac output C) Decreased heart rate D) Decreased venous return

D) Decreased venous return Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.

35. Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression. As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring? A) Urinary output increases B) Skin becomes warm and dry C) Adventitious lung sounds occur in the upper airway D) Heart and respiratory rates are elevated

D) Heart and respiratory rates are elevated As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the patient begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., renal failure, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.

The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient? A) It promotes coping and slows catecholamine release. B) It stimulates the patient so he or she is more alert. C) It decreases gastric secretions. D) It dilates the blood vessels.

D) It dilates the blood vessels. For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patient's anxiety. Morphine would not be ordered to promote coping or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions.

25. In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? A) It slows the proliferation of bacteria and viruses during shock. B) It decreases the energy expended through the functioning of the GI system. C) It assists in expanding the intravascular volume of the body. D) It promotes GI function through direct exposure to nutrients.

D) It promotes GI function through direct exposure to nutrients. Parenteral or enteral nutritional support should be initiated as soon as possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feeding. Enteral feeding does not decrease the proliferation of microorganisms or the amount of energy expended through the functioning of the GI system and it does not assist in expanding the intravascular volume of the body.

40. An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk of septic shock? A) Apply an antibiotic ointment to the patient's mucous membranes, as ordered. B) Perform passive range-of-motion exercises unless contraindicated C) Initiate total parenteral nutrition (TPN) D) Remove invasive devices as soon as they are no longer needed

D) Remove invasive devices as soon as they are no longer needed Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.

32. The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? A) To prevent the formation of infarcts of emboli B) To limit stroke volume and cardiac output C) To prevent pulmonary and peripheral edema D) To maintain adequate mean arterial pressure

D) To maintain adequate mean arterial pressure Vasoactive medications can be administered in all forms of shock to improve the patient's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.

9. When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal? A) Provide a detailed diagnosis and plan of care in order to promote the patient's and family's coping. B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.1

D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the patient the best chance for survival. Monitoring for significant changes is critical, and evaluating patient outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.

Which problem places the client at highest risk for septic shock? A. Stage III Chronic Kidney Disease B. Cirrhosis C. Lung cancer D. 40% burn injury

D. 40% burn injury

When caring for an obtunded ED client with shock of unknown origin, which action should the nurse take first? A. Establish IV access and hang prescribed infusion B. Apply the automatic BP cuff C. Assess level of consciousness and pupil response to light D. Check the airway and respiratory status

D. Check the airway and respiratory status When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? A. Client with urine output of 40 mL/hr for the last two hours B. Client with a pulse change of 100 to 88 beats per minute C. Client with oxygen saturation unchanged at 94% D. Client with a blood pressure change of 128/74 to 110/88 mm Hg

D. Client with a blood pressure change of 128/74 to 110/88 mm Hg

A nurse is caring for several clients at risk for shock. Which lab value requires the nurse to communicate with the healthcare provider? A. sodium 150 mEq/L B. Creatinine 0.9 mg/dL C. White blood cell count: 11,000/mm3 D. Lactate: 6 mmol/L

D. Lactate: 6 mmol/L

A nurse is caring for a client after surgery who is restless and apprehensive. The UAP reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? A. Assess the client for pain or discomfort B. Stay with the client and reassure him or her C. Reposition the client to the unaffected side D. Measure urine output from catheter

D. Measure urine output from catheter

Which of the following indicate early sepsis, which has an excellent recovery rate if treated promptly? A. Localized erythema and edema B. Low-grade fever & low white blood cell count C. Low oxygen saturation & decreased cognition D. Reduced urinary output & increased respiratory rate

D. Reduced urinary output & increased respiratory rate

The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock? a. "Is your blood pressure higher than usual?" b. "Are you having pain in your throat?" c. "Have you been vomiting?" d. "Are you usually this swollen?"

D: Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.

The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client's shock is caused by sepsis? a. Hypotension b. Pale clammy skin c. Anxiety and confusion d. Oozing of blood at the IV site

D: The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock.

Sepsis Bundle of Care Complications

DIC Commonly caused by sepsis Occurs because of enhanced coagulation that results from the release of procoagulant factors as part of the inflammatory response associated with sepsis Two phases: a clotting, or thrombotic, phase and a bleeding phase MODS Multiple organ dysfunction syndrome (MODS) is another complication that occurs as a result of the excessive inflammation associated with severe injury or sepsis The cause of MODS is multifaceted

Neurogenic shock assessment and analysis

Decreased CO Bradycardia May appear pink and flushed

Obstructive Shock Clinical Manifestations

Decreased LOC Decreased urine output Poor pulses Pale, cool skin Decreased bowel sounds Chest pain N/V SOB

The nurse is reviewing diagnostic and laboratory studies performed for an older adult patient with influenza. Which result should the nurse recognize as being consistent with influenza?

Decreased white blood cell count

Transmission of COVID

Direct transmission from one person to another is though to be the primary means of COVID transmission Highest risk of transmission is though to come with close contact via respiratory droplets Droplets are produced during coughing, sneezing, laughing, singing, and even talking Transmitted directly from person to person via contact Indirect contact transmission COVID present on surfaces through human contamination can be transferred to the mucus membranes of the mouth, eyes, or nose It is unknown low long COVID can survive on surfaces Depends on temperature, humidity, and amount of virus present Contact and droplet transmissions are the highest contributors to viral spread Evidence that virus can be aerosolized This mode of transmission has safety implications

Distributive Shock

Distributive shock is the result of disease states that cause poor vascular tone and vasodilation, resulting in increased vascular capacity and venous pooling Neurogenic shock Caused by loss of vasomotor tone Anaphylaxis Caused by release of histamine, which results in vasodilation, decreased venous return, and hypotension

Influenza Pathophysiology

Droplet transmission Small droplets from infected person's sneeze, cough, or direct contact Incubation period Approx 18-72 hrs Virus Shedding Usually ends 2-5 days after symptoms first appear Infectious for 7-10 days Types A,B, and C A and B are responsible for epidemics of respiratory illness that occur mostly during winter months

TB pathophysiology

Droplet transmission Small infected droplets are inhaled and remain within the upper airway and rarely cause active disease Classified as the following Latent TB infection (LTBI) Primary TB infection (PTBI) Primary progressive TB infection (PPTBI) Drug-Resistant MTB (MDR TB)

Medical Management of Cardiogenic Shock

ECG, cardiac enzymes, chest X-ray Rule out MI Airway oxygenation Emergency revascularization, mechanical circulatory support VAD may need to be used if not successful Vasopressors, inotropes Vasopressors Dopamine Norepinephrine Sustain blood pressure Maintain MAP Inotropes Dobutamine Increases myocardial contractility

Sepsis Assessment and Analysis

Early Signs Initial increase in CO Warm and flushed skin Bounding pulses Late signs Hypotension Tachycardia Tachypnea Decreased LOC Weak pulses Cold, cyanotic, mottled skin Decreased urine output Hypoactive bowel sounds Complications Enhanced coagulation Necrotic extremities Excessive bleeding

COVID nutrition

Early nutrition should not be delayed Patients should be consuming nutrition relative to their ability to eat by mouth Intubated patients should be fed enterally through NG or OG tubes

Sepsis Clinical Manifestations

Early stage Tachycardia Bounding pulses Fever Late Stage Cool, pale skin Weak, thready pulses Tachycardia Hypotension

Risk Factors of Cardiogenic Shock

End stage heart failure Cardiomyopathy HTN Diabetes Multi-vessel disease Acute vascular disease

A patient presents to the emergency room with suspected anaphylactic shock. Based on this information, which medication will be administered?

Epinephrine first (IM injection), then possibly Benadryl or steroids later, apply oxygen

Sepsis bundle of care Fluid Resuscitation

Essential to restore hemodynamic stability, maximize CO2, and begin repaying oxygen debt A crystalloid solution such as normal saline or lactated Ringer's is commonly used to improve and maintain filling pressures Evidence suggests that aggressive resuscitation in early sepsis has been shown to decrease mortality Fluid resuscitation should be tapered as the patient demonstrates improvement

The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the disease when educating the patient? Select all that apply.

Fatigue Weight loss Night sweats

Clinical manifestations of COVID

Fever Cough Dyspnea Headache Fatigue Myalgias New smell and taste disorders N/V, and/or diarrhea Rare Dermatitis, rash, and petechiae

Clinical Manifestations of HIV

Fever Cough Weakness N/V Diarrhea Dysphagia Forgetfulness Skin lesions SOB Dyspnea on exertion Headache Vision changes Penlight sweats Enlarged lymphnodes

Influenza Clinical Manifestations

Fever Headache Sore throat Severe nasal congestion Cough Myalgia Muscle aches and pains Malaise Fatigue

A patient in cardiogenic shock requires vasopressor therapy. What does this type of therapy require?

Fluids before vasopressors, insertion of central line, continuous monitoring of BP, insertion of A line, careful titration of vasopressors

COVID Community Prevention

Follow current guidelines for prevention Maintain good hand hygiene Maintain social distance Use facial covering Avoid large crowds Limit travel Follow existing standards and protocols instituted by local, state, national mandates during the pandemic

Sepsis Bundle of Care Ongoing monitoring

Frequent assessment of vital signs, peripheral perfusion, mental status, cultures, and laboratory analyses, including white blood cell count and differential and lactate, are essential Hemodynamic parameters such as CVP or PAOP and SvO2 or ScvO2 help monitor responsiveness to therapy, but the use of a PA catheter, and thus PAOP and SvO2, is not recommended because the PA catheter has not been shown to have an improved impact on outcomes Instead, monitoring of responsiveness to therapy can be done through evaluation of CVP and ScvO2 in combination with dynamic measures such as monitoring cardiac output through echocardiology after a passive leg raise (PLR) maneuver An increase in cardiac output demonstrates a good response to fluid resuscitation.

In planning care for shock patients, the nurse understands that typically isotonic fluids are used as replacement therapy. However, at times, other types of parenteral fluids such as hypertonic fluids may be used. What rationale would account for the use of different types of fluid replacement?

Give hypertonic solutions to help fluids rush into the vessels to counter act the sodium, which will help decrease the edema. Give albumin to increase the oncotic pressure and help pull fluids from the extracellular spaces back into the vessels; helps give patients more protein to balance fluid; sometimes give lasiks and albumin together to increase response to diuretic

HIV Diagnostic Testing

HIV virus antibodies CD4 count Obtained routinely every 3-6 months for the first two years Viral load Obtained every 3 months for the first 2 years on therapy Used as primary indicator of treatment success or failure Not recommended as an indicator for hospitalized patients

Cardiogenic Shock Hemodymanic Parameter

Heart fails; caused most commonly from massive MI or any myocardial damage (End stage HF) Decreased CO; low BP; high HR; normal or elevated CVP; Low ejection fraction

Cardiogenic Shock Physiologic Response

Heart has low EF and cannot pump; use the intraortic balloon pump (IAPB) to help heart pump easier; helps perfuse coronary arteries; CABG if needed or LVAD (Left ventricular assistive device)

Neural compensation of shock

Heart rate and contractility increase, improving cardiac output In response to this catecholamine release, systemic vasoconstriction occurs, resulting in increased blood pressure and redistribution of blood flow from nonessential organ systems, such as the kidneys, GI tract, and skin, to vital organs, such as the heart and brain

COVID Diagnosis

High clinical suspicion: New-onset fever Upper respiratory symptoms (dyspnea and cough) New-onset oxygen requirement with no clear cause COVID-19 hotspot Close contact with a known or suspected case of covid Clinical exam Chest- Xray Bilateral ground-glass opacities toward bases Chest CT Diagnostic Testing NAAT PCR testing Serum antibody testing Less likely to be reactive in the first days to weeks of an infection

TB Risk Factors

Homeless and incarcerated populations Persons with HIV or AIDS Populations living outside the USA Low socioeconomic groups that have obstacles accessing health care Racial and ethnic minorities

Pneumonia risk factors

Hospital acquired Occurs within 48hrs of hospital admission Recent antibiotic therapy Immunosuppression Chronic disease Treatment in healthcare facilities Dialysis centers Adult daycare Rehab facilities

TB Nursing Actions

Humidified oxygen Airborne isolation Administer antibiotics as ordered Ensure adequate nutrition

Anaphylactic pathophysiology

Hypersensitivity reaction Histamine reaction Widespread venous dilation Increased capillary permeability Smooth muscle contraction

Sepsis bundle of care Vasopressors

If fluid resuscitation is not successful at restoring blood pressure during or after administration, initiation of vasopressors to maintain a mean arterial pressure greater than 65 mm Hg may become necessary The Surviving Sepsis campaign suggests the use of norepinephrine as the first-line vasopressor

HIV Asymptomatic chronic infection

Immune system begins to exert control but is not able to eliminate viral replication CD4 count increases to near normal and viral load drops to set-point level Viral set point Occurs when viral replications is still taking place, but the immune system is able to destroy the virus in equal amounts

Cardiogenic shock

Inadequate pumping of the heart muscle, most typically the result of a heart attack.

An older adult patient is admitted with pneumonia. Which manifestation is unexpected during the nurse's initial assessment?

Increased appetite

The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this patient?

Ineffective Therapeutic Regimen Management

Pneumonia Pathophysiology

Inflammation of lung parenchyma from bacterial, viral, fungal infection

Neurogenic shock clinical manifestions

Warm, dry skin Flushed appearance Decreased CO Decreased systemic vascular resistance

Influenza nursing actions

Initiate isolation precautions Droplet precautions Administer humidified supplemental oxygen Reverse hypoxia Maintain moist respiratory mucosa Semi to high fowler's Relief of nasal drainage Promotes optimal lung expansion Prevents atelectasis Prevent aspiration Administer medications as ordered Fever reduction Antivirals Analgesics Pain relief can increase comfort Provide adequate medications as ordered Helps respiratory secretions Provide nutritional intake Essential for cell recovery Obtain cultures

Sepsis/Septic Shock Pathophysiology

Invasion of pathogen initiates a series of complex responses by the host's immune system Deregulated host response to infection Excessive release of proinflammatory cytokines Vasodilation Decreased vasomotor tone Increased capillary permeability

The nurse is caring for a patient who is admitted to the unit with tuberculosis (TB). The patient is placed in isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most appropriate?

Isolation room with an anteroom and negative air flow (air flows into the room.)

Pneumonia Diagnosis

Lab studies Elevated WBC count with elevated bands on differential indicating acute inflammation Elevated CRP level Can range from 30-300mg/dL ABGs may reflect respiratory alkalosis (decreased CO2, increased pH) initially Reflect respiratory acidosis as progresses Sputum cultures Imaging studies Chest X-Ray CT scan

TB Diagnosis

Laboratory testing Sputum test/culture Acid-Fast staining Skin test PPD testing (Mantoux test) Observe 48-72 hrs after injection Immunized indvs will have a positive PPD Chest x-ray If have positive PPD

Which laboratory testing would provide the healthcare provider with the most accurate understanding of the progression of the patient's shock state?

Lactic Acid (lactate)

Shock

Life Threatening syndrome Circulatory system unable to supply adequate oxygen to tissues to meet metabolic demand Creates a state of tissue hypoxia Without immediate treatment Organ system failure Death

Hypovolemic Shock Hemodymanic Parameter

Massive fluid loss from burns, trauma, hemorrhage Decreased CO; low CVP; low BP; high HR

Obstructive Shock Pathology

Mechanical barrier to ventricular filling or emptying Decreased cardiac output Impaired tissue perfusion Caused by DVT or PE

Sepsis Nursing Actions

Meticulous hand washing and aseptic technique with all procedures Hand washing and aseptic techniques are basic interventions to help prevent and control infection. Administer oxygen as ordered Maximizing oxygenation is essential Anticipate and prepare for intubation Intubation and mechanical ventilation may be required to improve oxygenation or if respiratory failure ensues Obtain lactate level Lactate levels are an indicator of adequacy of perfusion; increased levels signal the presence of anaerobic metabolism Obtain two blood cultures from two different sites, or obtain urine, sputum, and wound cultures Cultures are obtained to identify the offending organism Administer antibiotics as ordered after cultures are obtained Antibiotics are the first-line treatment in an attempt to control the infection Administer fluid replacement as ordered Aggressive fluid replacement is the initial treatment to restore filling volumes and blood pressure in septic shock Administer vasoactive drips such as norepinephrine as ordered Vasoactive drips may be necessary to restore vascular tone if fluid replacement therapy is not effective at increasing blood pressure and cardiac output Provide mouth care every 4 hours and when needed Oral care is effective at reducing the occurrence of ventilator-associated pneumonia

Pneumonia Complications

Necrotizing pneumonia Fibrosis and scarring of the lung tissue Empyema Collection of purulent material in the pleural space Should be drained by a chest tube Bacteremia Bacteria in the bloodstream Pneumothorax Sepsis Acute respiratory failure Multiple organ failure

Obstructive Shock Physiologic Response

Need paracardiocentesis (aspirate fluid from heart to relieve pressure)

Sepsis Nursing Assessments

Neuro status Decreased level of consciousness occurs a result of decreased cardiac output Vital signs Hypotension is present because of vasodilation, producing relative hypovolemia and decreased venous return Tachycardia will be present as one of the compensatory mechanisms Initially, the patient will be febrile as an adaptive response In later stages, the patient will be hypothermic, potentially signaling the body's inability to continue the adaptive response. Hemodynamic readings Initially, cardiac output is increased As sepsis progresses, cardiac output decreases as a result of continued decreases in filling pressures, such as right atrial and pulmonary artery occlusion pressures Initially, systemic vascular resistance is decreased as a result of widespread vasodilation Later, it may increase due to compensation and vasopressor therapy Urine output Decreased urine output occurs as a result of decreased cardiac output Skin color and temperature Initially, the patient's skin is flushed and warm because of increased cardiac output Later, the skin becomes cold and clammy, signaling the progression of shock Tissue necrosis in the extremities may indicate the enhanced coagulation of DIC Bleeding Excessive bleeding from wounds and puncture sites may be present because of consumption of clotting factors in DIC

Clinical Manifestations of HIV indications a deterioration in status requiring immediate attention by an HCP

New cough Increased fatigue Fever less than 97F or greater than 102F Night sweats New onset of headache New onset of visual blurring Recent change in mental status New skin lesions New onset of diarrhea Weight loss greater than10% of previously recorded weight

What vital sign changes would the nurse expect to see in a patient who is in the initial state of shock prior to receiving any medical treatment?

Normal/slightly high blood pressure, temp may be slightly warm

Hypovolemic shock medical management

Optimize oxygenation Fluid resuscitation Identify and treat underlying cause Fluid Blood products

Pneumonia Treatment

Oxygen administration Reverse or prevent hypoxia Adequate hydration Support CV status Thins respiratory secretions

COVID Inpatient management

Oxygen therapy Nasal Cannula High-flow nasal cannula (HFNC) Noninvasive ventilation (NIV) Mechanical ventilation The decision to intubate a patient who is rapidly deteriorating should never be delayed Ventilator management of the COVID19 patient follows similar principles for patients with ARDS caused by viral pneumonia Prone positioning Prone positioning of awake, nonintubated patients is shown to increase peripheral oxygen saturation Prone position has been used therapeutically to treat hypoxemia in ARDS When a patient is proned, the aerated upper part of the lung is palced below the areas of atelectasis and fluid accumulation, better matching aeration to perfusion Extracorporeal membrane oxygenation (ECMO) Severe ARDS often leads to very "stiff" lungs (non-compliant) Even with very low tidal volumes, lung pressures to increase to dangerous level Ventilation and CO2 exchange can become a significant challenge Tracheostomy

. A patient admitted to the emergency room with hemorrhagic shock requires blood transfusions to restore circulating blood volume. What type of blood product would the nurse expect the physician to order?

Packed RBCs, isotonic fluids (lactated ringers, normal saline)

Care of the Prone Patient

Pad all boney prominences with foam absorbent dressing including cheeks, knees, hips, and shoulders Mepilex used for managing chronic wounds Pad ears and nipples with mepilex Create pocket for penis; ensure it is not trapped under thigh Avoid anterior subluxation of shoulder Use moldable pillow for face, creating divot for ear, nose, and tube Position bed in reverse Trendelenburg to elevate head Turn patient at least every 4 hours to avoid pressure ulcer Can feed patient if tolerated; usually lower rates up to 20 mL/hr

Neurogenic Shock Physiologic Response

Parasympathetic nervous system is not opposed by sympathetic nervous system, so para takes over

Bucking The Vent

Patient on ventilator who is fighting against the vent, trying to breathe on their own; feel like they can't breathe even though they are on the ventilator; Try to calm them down first and meet their needs; help them communicate (write things on a board, pointing); give sedative or paralytic to help them work with the ventilator

COVID outpatient management

Patient self-assessments First line triage Monitor own symptoms Telephone triage Risk-stratification tool Risk stratification and in-person outreach if needed Telehealth Testing Management of all outpatients should include reinforcement of infection control practices such as self-isolation, hand hygiene, and use of masks in communal areas Patients should be educated on symptoms management and recovery expectations

The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a patient with pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the nurse include in this patient's plan of care?

Perform chest percussion every four hours and prn

Compensatory Stage of Shock

Physiologic Process: Compensatory mechanisms in place Manifestations: Narrow pulse pressure (improve CO for a little while) Decrease in urine output Increased RR, respiratory alkalosis Cool skin Weak pulses Tachycardia Decrease in MAP

Progressive Stage of Shock

Physiologic Process: Failure of compensatory mechanisms Manifestations: Rapid, weak pulse Significant drop in BP Anuria (kidneys shutting down) Respiratory acidosis (lungs shutting down) Cold extremities

Initial Stage of Shock

Physiologic Process: Lower levels of O2 in cells (not always caught on monitor, not hypoxic yet); tissue ischemia is starting to occur; subtle changes Manifestations: Hyperdynamic at first (warm, flushed skin, hypoxic, mild vasoconstriction, normal/high BP) Lactate increasing Lower CO, but may not be noticeable yet

Refractory Stage of Shock

Physiologic Process: Prolonged inadequate O2 supply to the cells Manifestations: MODS Shallow respirations Severe low BP Liver/kidney failure: high bili, high creat, low plt, high PTT/INR Metabolic acidosis (bicarb no longer produced) Massive tissue ischemia=COMA (unarousable) MAP < 65 Lactate > 4 Systolic dropped at least 40 pts Anuria

1. Regardless of the type of shock state identified, what are priority treatment interventions aimed at?

Place patient on oxygen, administer IV fluids, implement hemodynamic monitoring through a PA catheter, monitor urine output (possible decreased), assess vital signs, assess skin (pale, diaphoretic), assess capillary refill (slower), draw labs (Lactate, blood culture, ABGs, PTT/INR, Bili, BUN/Creat), remove invasive lines (could be source of infection)

The nurse is planning care for a patient diagnosed with influenza. Which intervention should the nurse include when planning this patient's care?

Placing droplet and contact precaution signs on the patient room door

During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which diagnosis presents with this assessment finding?

Pneumonia

An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, for which potential risk should the nurse include when planning care for this patient?

Pneumothorax

Evaluating COVID Care outcomes

Post-intensive care syndrome (PICS) Cognitive effects Emotional challenges Physical weakness PTSD Interventions required to sedate and chemically paralyze patient can lead to Delirium Anxiety Depression Confusion Cognitive deficits Muscle loss Weakness Impact of social isolation from friends and family Patient discharge to rehab centers or skilled nursing centers can be altered Longer inpatient hospitalization or delay in rehab Long-term impact of COVID is still under investigation COVID is not solely a respiratory illness and has systemic impacts As the pandemic continues, more information on the impact of illness on patient, family, and society will be discovered

COVID Prevention

Practice social distancing Wear a mask Wash hands frequently Avoid touching face, in particular mucous membranes such as eyes, nose, and mouth Cover cough and sneezes with elbow

A patient with the flu is experiencing tachypnea. What intervention is inappropriate to address in the nursing diagnosis of Ineffective Breathing Pattern related to the flu?

Prepare the patient for the possibility of a tracheostomy tube.

COVID Isolation at home

Prevent potential transmission among family members Teach importance of hang hygiene, social distancing, face mask use, avoiding touching face Consider not sharing commonly shared items such as utensils, plates, glasses, cups Use separate bathrooms and bedrooms if possible Teach importance of cleaning environment, hand hygiene, social distancing

Medical Management of Sepsis

Prevention Hand washing Aseptic technique for procedures Elimination of invasive therapies when possible Aggressive mouth care in vented patients Brushing teeth with chlorhexidine products

Influenza Treatment

Prevention--Vaccination Annual vaccine Side effects Low grade fever Soreness at injection site Individuals with an allergy to eggs should not receive this vaccine Best time of year to get is early fall before flu season

TB Clinical Manifestations

Primary TB Asymptomatic and not infectious Confirmed with positive sputum cultures and positive skin test Symptomatic TB infection Fatigue Weight loss Night sweats Cough Rust colored sputum Blood streaked sputum Dyspnea Orthopnea Rales DRM TB One or more first line medications used for TB treatment is not working Primary resistance Caused by person to person transmission of resistant organism Secondary resistance Develops during drug treatment

Refractory stage of shock

Prolonged inadequate blood supply to cells Cell death Multisystem organ failure Irreversible at this stage

HIV medications

Prophylaxis If has CD4 is less than 200, used to reduce risk of OIs Toxoplasmosis or PCP Antiretroviral Therapy (ART) Interfere with the ability of HIV to reproduce itself Immunizations Essential because HIV+ patients are more at risk for infections owing to their compromised immune systems Pneumovax every 5 years

Medical Management of Anaphylaxis

Removal of trigger If the trigger is the administration of antibiotics or blood, the infusion should be stopped immediately If the trigger is a bee sting, the stinger should be removed IM epinephrine First treatment priority Preferred route Provides a consistent, rapid rise in therapeutic concentration and lowers risk of CV complications Maintain patient airway 100% nonrebreather Preparing for intubation Circulatory support IV fluid Antihistamines, corticosteroids, inhaled bronchodilators

TB Complications

Respiratory failure Bronchoplueral fistula Pleural effusions Meningitis Lymphadenopathy Bone disease Liver and kidney failure

HIV Complications

Respiratory infections CD4 500-300 Dermatologic manifestations Herpes zoster CD4 500-300 Increase in infections CD4 between 350-200 Fever Fatigue Severe bacterial infections CD4 below 200 PCP Cryptococcal meningitis Cryptosporidiosis Candid esophagitis Toxoplasmosis CMV MAC PML Reconstruction inflammatory syndrome (IRIS) Occurs when CD4 count increases and the immune system is able to response to the presence of previously acquired OIs Response is overwhelming inflammatory response. making symptoms worse

Hypovolemic shock clinical manifestations

Restlessness or confusion Decreased urine output Pale, cool, clammy skin Weak pulses Delayed capillary refill Hyperventilation>resp alkalosis Hypoactive bowel sounds Hyperglycemia

Anaphylactic Shock Physiologic Response

Results in decreased CO b/c of massive vasodilation and capillary leak causing BP drop; immune system is pumping out histamine

Hypovolemic Shock

Results when there is a rapid fluid loss resulting in inadequate circulating volume. H Hypovolemic shock is secondary to blood loss from trauma or severe GI bleed.

Risk Factors for COVID

Risk factors in determining severe illness include age, comorbidities, and demographics DM HTN Obesity Chronic kidney disease Chronic lung disease Cancer Smoking

Clinical Manifestations of Anaphylaxis

SOB Tachypnea Wheezing Stridor Cyanosis Confusion Urticaria

Sepsis bundle of care Blood work

Serum lactate Blood cultures (two sets) CBC Coagulation studies Liver function tests ABGs

The nurse is caring for a patient who develops a fever and productive cough after having an appendectomy. Which prescriptions should the nurse expect from the health-care provider for this health problem? Select all that apply

Sputum cultures Antibiotics Chest physiotherapy

Chemical compensation of shock

Stimulated by low oxygen levels Low oxygen levels occur as a result of decreased blood flow through the alveoli Tachypnea, or hyperventilation, occurs in an effort to increase circulating oxygen levels The respiratory alkalosis that results causes a constriction of the carotid arteries.

Neurogenic shock pathophysiology

Sympathetic nervous system disruption Decreased vascular tone Increased peripheral vascular volume Decreased venous return Decreased CO>relative hypovolemia Unopposed parasympathetic activity> profound bradycardia Systemic hypoperfusion

Influenza Medications

Symptoms control Antipyretics Analgesics Antivirals Adequate fluid intake Rest Serious flu infection Antiviral medications Does not "cure" the flu Reduces severity of infection Best results when used within 24-48hrs of symptom onset

What are the criteria for SIRS?

T: temperature >100.4 or <96.8 HR: About 90bpm RR: Above 20 WBC: >12000 or <4000 Any two of the above will meet the criteria for SIRS If two criteria met, check history to see if they have condition that would cause sepsis

HIV Nursing Assessments

Temperature, pulse, respirations, oxygen saturation Fever is often first indicator of infection Low grade fever Weight trends Weight loss results from caloric expenditure exceeding caloric intake and can affect cellular metabolism CD4 count Correlation between CD4 count and the risk of developing certain OIs Viral load Reflects amount of viral replications Indicator of disease progression Adherence to ART Adherence rate of 95% or greater is essential to achieve viral suppression and prevent development of resistance to one or more ART medications TB status Increase in HIV individuals

Distributive shock

The result of disease states such as sepsis, anaphylaxis, or neurogenic shock that cause poor vascular tone and vasodilation, resulting in increased vascular capacity and venous pooling

COVID Treatment

There is not cure for COVID Treatment is largely supportive care of the patient while the immune system fights off the infection There are emerging pharmaceutical options along with vaccine development and ongoing clinical trials Emergency use vaccines became available in 12-2020 Vaccinations in selected high risk individuals (front line staff, essential workers, elderly, nursing home residents and others) began as preventative public health measure

Neurogenic Shock medical management

Treat cause Providing CV support Cautious fluid resusitation Vasoactive IV meds Fluid resuscitation Vasoactive medications Dopamine, epinephrine, norepinephrine, phenylephrine Atropine Transcutaneous or transvenous pacing Ventilatory support

Obstructive Shock Medical Management

Treat cause Supplemental oxygen Vasoactive infusion

The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this patient?

Tuberculosis

HIV Risk factors

Unprotected sex IV Drug use Blood containing HIV virus is injected into the bloodstream of uninfected indv from infected indv from the sharing of needles Blood transfusions VERY small amount (0.36%) Pregnant women Can be transmitted to the child through sharing of vaginal fluid in birth canal Can be spread through breastmilk to child with a breast feeding mother

HIV Nursing Actions

Utilize universal precautions consistently Prevent spread of infection Handwashing!!! PPE may be needed Administer ART as prescribed and on time Maintain medications levels Several medications are frequently use Provide nutritionally dense foods and small, frequent meals Anorexia, N/V are commonly seen in idv with HIV/AID Can lead to dehydration, weight loss, and electrolyte imbalances Incorporating foods such as nuts or nutritional supplements Provide emotional support Complex emotional issues, such as sexuality, shame, and danger

Hypovolemic shock assessment

Varies depending upon stage of shock Progressive Hypotension Tachycardia Weak pulses Tachypnea

Influenza Diagnosis

Viral Culture Sampling from respiratory secretions Can take up to 10 days Rapid influenza diagnostic tests Nasopharyngeal/throat swab Results within 30 minutes Specific to current circulating flu Negative test does not necessarily mean no flu History and physical

HIV Viral transmission, viral infection, and seroconversion

Virus causes an inflammatory reaction, bringing while blood cells and macorphages to the site of inoculation Virus particles attach to CD4 receptors, cells, and co-receptors and enters cell

The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being transported to the unit. Which nursing action for infection prevention is the most appropriate in this circumstance?

Wear a respirator mask and gown when caring for the patient

A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient? a. "The EIA test will need to be repeated to verify the results." b. "A viral culture will be done to determine the progression of the disease." c. "It will probably be 10 or more years before you develop acquired immunodeficiency syndrome (AIDS)." d. "The Western blot test will be done to determine whether acquired immunodeficiency syndrome (AIDS) has developed."

a

An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching? a. Many medications have interactions with antiretroviral drugs. b. Less frequent CD4+ level monitoring is needed in older adults. c. Hospice care is available for patients with terminal HIV infection. d. Progression of HIV infection occurs more rapidly in older patients.

a

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay

a

Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation

a

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with patient vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure

a

The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

a,b,c

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Continue taking antibiotics until all the medication is gone. b. Antibiotics may sometimes be prescribed to prevent infection. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

a,b,e

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Avoid sexual intercourse when using injectable drugs." b. "It is important to participate in a needle-exchange program." c. "You should ask those who share equipment to be tested for HIV." d. "I recommend cleaning drug injection equipment before each use."

b

A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART).

b

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time? a. Teach about the effects of antiretroviral agents. b. Encourage adequate nutrition, exercise, and sleep. c. Discuss likelihood of increased opportunistic infections. d. Monitor for symptoms of acquired immunodeficiency syndrome (AIDS).

b

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time? a. Oral acyclovir (Zovirax) b. Oral saquinavir (Invirase) c. Nystatin (Mycostatin) tablet d. Aerosolized pentamidine (NebuPent)

b

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient about how to use tissues to dispose of respiratory secretions. b. Stock the patient's room with all the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.

b

According to the Center for Disease Control (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium difficile (select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

b,c

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

c

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/uL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient meets the criteria for a diagnosis of an acute HIV infection." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient has developed acquired immunodeficiency syndrome (AIDS)." d. "The patient will develop symptomatic chronic HIV infection in less than a year."

c

A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient about the medications available for treatment. b. Inform the patient how to protect sexual and needle-sharing partners. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to notify individuals who have had risky contact with the patient.

c

A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Driving is allowed when starting this medication. b. Report any bizarre dreams to the health care provider. c. Continue to use contraception while on this medication. d. Take this medication in the morning on an empty stomach.

c

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

c

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Advise the patient that this is probably the flu. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.

c

Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose latest CD4+ count is 250/µL b. Patient whose rapid HIV-antibody test is positive c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs

c

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is best? a. "Thinking about dying will not improve the course of AIDS." b. "It is important to focus on the good things about your life now." c. "Do you think that taking an antidepressant might be helpful to you?" d. "Can you tell me more about the kind of thoughts that you are having?"

d

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. HIV genotype and phenotype b. Patient's social support system c. Potential medication side effects d. Patient's ability to comply with ART schedule

d

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.

d

The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient's blood glucose level is 142 mg/dL. b. The patient complains of feeling "constantly tired." c. The patient is unable to state the side effects of the medications. d. The patient states, "Sometimes I miss a dose of zidovudine (AZT)."

d

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µL c. HIV-positive patient with a CD4+ count of 160/µL who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

d

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the drugs should be taken.

d