Shock Practice Questions
The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter .2. Administer dopamine intravenous infusion. 3. Obtain arterial blood gases (ABGs). 4. Insert an indwelling urinary catheter.
1. There are many types of shock, but the one common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicates hock. 2. This blood pressure does not require dopamine; fluid resuscitation is first. 3. The client may need ABGs monitored, but this is not the first intervention. 4. An indwelling catheter may need to be inserted for accurate measurement of out-put, but it is not the first intervention
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.
2 2.These client's signs/symptoms make the nurse suspect the client is losing blood,which leads to hypovolemic shock,which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging 1. Cardiogenic shock occurs when the heart's ability to contract and pump blood is impaired and the supply of oxygen to the heart and tissues is inadequate, such as occurs in myocardial infarction or valvular damage. 3. In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. It can result from the depressant action of medication or lack of glucose. 4. Septic shock is a type of circulatory shock caused by widespread infection
The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client? 1. Cool moist skin. 2. Bradycardia. 3. Wheezing. 4. Decreased bowel sounds.
2 The client will have bradycardia instead of tachycardia, which is seen in other forms of shock. 1. The client diagnosed with neurogenic shock will have dry, warm skin, rather than cool, moist skin as seen in hypovolemic shock. 3. Wheezing is associated with anaphylactic shock. 4. Decreased bowel sounds occur in the hyperdynamic phase of septic shock.
The client diagnosed with septicemia has the following health-care provider orders.Which HCP order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks.
2. An IV antibiotic is the priority medication for the client with an infection,which is the definition of sepsis—a systemic bacterial infection of the blood.A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order. 1. The client's diet is not priority when transcribing orders. 3. Diagnostic tests are important but not priority over intervening in a potentially life-threatening situation such as septic shock. 4. There is no indication this client has diabetes in the stem of the question, and glucose levels are not associated with signs/symptoms of septicemia.
The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock? 1. Monitor the client's telemetry. 2. Turn the client every two (2) hours. 3. Administer oxygen via nasal cannula. 4. Place the client in the Trendelenburg position.
3 Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock. 1. Monitoring the telemetry will not prevent cardiogenic shock. It might help identify changes in the hemodynamics of the heart,but it does not prevent anything from occurring. 2. Turning the client every two (2) hours will help prevent pressure ulcers, but it will do nothing to prevent cardiogenic shock. 4. Placing the client's head below the heart will not prevent cardiogenic shock. This position can be used when a client is in hypovolemic shock
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4 ̊F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000/mm3. 3. A urinary output of 90 mL in the last four (4) hours. 4. The client complains of being thirsty.
3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last four (4) hours indicates impaired renal perfusion, which is a sign of worsening hock and warrants immediate intervention. 1. These vital signs are expected in a client with septic shock. 2. An elevated WBC count indicates an infection, which is the definition of sepsis. 4. The client being thirsty is not an uncommon complaint for a client in septic shock.
The nurse caring for a client with sepsis writes the client diagnosis of "alteration in comfort R/T chills and fever." Which intervention should be included in the plan of care? 1. Ambulate the client in the hallway every shift. 2. Monitor urinalysis, creatinine level, and BUN level. 3. Apply sequential compression devices to the lower extremities. 4. Administer an antipyretic medication every four (4) hours PRN.
4 Antipyretic medication will help decrease the client's fever, which directly addresses the etiology of the client's nursing diagnosis. 1. Ambulating the client in the hall will not address the etiology of the client's chills and fever; in fact, this could increase the client's discomfort. 2. Monitoring these laboratory data does not address the etiology of the client's diagnosis. 3. Sequential compression devices help prevent deep vein thrombosis.
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic.Which laboratory data require the nurse to notify the health-care provider? 1. The client's potassium level is 3.8 mEq/L. 2. The urine culture indicates high sensitivity to the antibiotic. 3. The client's pulse oximeter reading is 94%. 4. The culture and sensitivity is resistant to the client's antibiotic
4. A sensitivity report indicating a resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organ-ism, and the HCP needs to be notified so the antibiotic can be changed. 1. This is a normal potassium level (3.5 to5.5 mEq/L); therefore, the nurse does notneed to notify the HCP. 2. A culture result showing a high sensitivity to an antibiotic indicates this is the antibiotic the client should be receiving. 3. A pulse oximeter reading of greater than 93% indicates the client is adequately oxygenated.
A 70 year old patient is malnourished, has a history of type 2 diabetes mellitus, and is admitted from the nursing home with pneumonia. For which kind of shock should the nurse closely monitor this patient? a. Septic Shock b. Neurogenic shock c. Cardiogenic shock d. Anaphylactic shock
A Older adults with chronic disease and malnourished or debilitated patients are at risk for developing septic shock, especially when they have an infection(e.g pneumonia, UTI) or indwelling lines or catheters.
What physical problems could precipitate hypovolemic shock? Select all that apply. a. Burns b. Ascites c. Vaccines d. Insect bites e. Hemorrhage f. Ruptured Spleen
A,B,E,F Hypovolemic shock occurs when there is a loss of intravascular fluid volume from fluid loss(as in hemorrhage or severe vomiting and diarrhea) fluid shifts(as in burns or ascites) or internal bleeding(as with ruptured spleen). Vaccines and insect bites would precipitate the anaphylactic type of distributive shock.
The patient is in the compensatory stage of shock. What manifestations indicate this to the nurse? Select all that apply: a. Pale and cool b. Unresponsive c. Lower BP than baseline d. Moist crackles in the lungs e. Hyperactive bowels sounds f. Tachypnea and tachycardia
A,C,F In the compensatory stage of shock the patient's skin will be pale and cool. There may also be a change in the LOC but the person will be responsive, the BP will be lower than baseline(can be normal too), BS will be hypoactive and tachypnea and tachycardia will occur. Unresponsiveness and moist crackles in the lungs in the progressive stage of shock.
In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates the adrenergic stimulation? Select all that apply: a. skin b. brain c. heart d. kidneys e. GI tract
A,D,E After SNS activation of vasoconstriction, blood flow to non-vital organs, such as skin, kidneys and GI tract is diverted to the most essential organs of the heart and the brain. The patient will feel cool and clammy, the RAAS will be activated and the patient may develop a paralytic ileus
he elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a Pulse of 110, BP 92/60. Which type of shock should the nurse report? a. Cardiogenic Shock b. Hypovolemic shock c. Neurogenic shock d. Septic Shock
B These clients s/s make the nurse suspect the client is losing blood, which leads to hypovolemic shock which is the most common type of shock and is characterized by decreased intravascular volume. The client taking NSAID medications put them at risk for hemorrhaging because NSAID inhibits prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging.
Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? 1. Reduced wheezing 2. Heart rate 55 and regular 3. Blood pressure 98/50 mm Hg 4. Respiratory rate 28
Correct Answer: 1 Rationale 1: An expected action for epinephrine is bronchodilation as evidenced by less wheezing. Rationale 2: Epinephrine increases heart rate. Rationale 3: Epinephrine increases blood pressure. Rationale 4: Epinephrine lowers the respiratory rate. This respiratory rate indicates that epinephrine has not been effective.
The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock? a. Monitor the client's telemetry b. Turn the client every 2 hours c. Administer oxygen via nasal cannula d. Place the client in the Trendelenburg position
C Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock.
When administering any vasoactive drug during the treatment of shock, the nurse should know that what is the goal of the therapy? a. Increase urine output to 50ml/hr. b. Constriction of vessels to maintain BP c. Maintaining a MAP of at least 60mmHG d. Dilating vessels to improve tissue perfusion
C Remember you want the MAP greater than 60-65.. To calculate the MAP you do 2x diastolic + systolic= then divide that number by 3. (This is the best answer) Vasoactive drugs are those that can either dilate or constrict blood vessels and are used in various stages of shock treatment. When using either vasodilators or vasoconstrictors, it is important to maintain a MAP of at least 60 so that adequate perfusion is maintained. The other goals would be appropriate only with either vasodilators or vasoconstrictors, not with all vasoactive drugs.
Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 8 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54%
Correct Answer: 1 Rationale 1: A CVP reading of 8 mm Hg is within normal range and rehydration has been restored. Rationale 2: The mean arterial pressure (MAP) should be between 60 to 70 mm Hg as evidence of positive fluid resuscitation efforts. Rationale 3: Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. Rationale 4: Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid-to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements.
A patient is being treated for pericarditis. The nurse will plan interventions to prevent the onset of which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic
Correct Answer: 1 Rationale 1: Acute pericarditis and the development of fluid accumulation in the pericardial space can lead to the development of obstructive shock. Rationale 2: Pericarditis is not a risk factor for the development of hypovolemic shock. Rationale 3: Pericarditis is not a risk factor for the development of distributive shock. Rationale 4: Pericarditis is not a risk factor for the development of cardiogenic shock.
A patient is diagnosed with cardiac tamponade. When planning care, the nurse will include interventions to address which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic
Correct Answer: 1 Rationale 1: Cardiac tamponade can lead to obstructive shock. Rationale 2: Cardiac tamponade will not lead to hypovolemic shock. Rationale 3: Cardiac tamponade will not lead to distributive shock. Rationale 4: Cardiac tamponade will not lead to cardiogenic shock.
A patient is demonstrating signs of obstructive shock but the cause has yet to be determined. Which finding indicates the patient is experiencing a pulmonary embolism as the cause for obstructive shock? 1. Chest pain 2. Hypotension 3. Tachycardia 4. Oliguria
Correct Answer: 1 Rationale 1: Chest pain is a symptom associated with a massive pulmonary embolus. Rationale 2: Hypotension is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus. Rationale 3: Tachycardia is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus. Rationale 4: Oliguria is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus.
A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: 1. Reduced cardiac output 2. Increased stroke volume 3. Reduced blood volume 4. Blood flow blocked in the pulmonary circulation
Correct Answer: 1 Rationale 1: In cardiogenic shock, cardiac output is reduced, leading to poor tissue perfusion. Rationale 2: In cardiogenic shock, stroke volume is decreased. Rationale 3: There is not a reduction of blood volume in cardiogenic shock. Rationale 4: There is not a blockage of blood flow through the pulmonary circulation in cardiogenic shock.
A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? 1. Jugular vein distention 2. Dry mucous membranes 3. Poor skin turgor 4. Thirst
Correct Answer: 1 Rationale 1: Jugular vein distention is a manifestation of cardiogenic shock. Rationale 2: The mucous membranes are not dry in cardiogenic shock. Rationale 3: The skin turgor is not poor in cardiogenic shock. Rationale 4: Thirst is not a manifestation of cardiogenic shock.
The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive
Correct Answer: 1 Rationale 1: One etiology of cardiogenic shock is a myocardial infarction. Rationale 2: Acute myocardial infarction does not cause hypovolemic shock. Rationale 3: Acute myocardial infarction does not cause distributive shock. Rationale 4: Acute myocardial infarction does not cause obstructive shock.
A patient is prescribed vasopressin 0.03 units/minute as treatment for septic shock. What action will the nurse take when providing this medication? 1. Provide the vasopressin infusion in addition to a norepinephrine infusion. 2. Infuse through a peripheral line. 3. Utilize a rapid infuser. 4. Administer with 0.9% normal saline.
Correct Answer: 1 Rationale 1: The dose of 0.03 units/min is usually added to a norepinephrine infusion. Rationale 2: This medication should always be administered via an infusion pump. Rationale 3: A rapid infuser is used to deliver large amounts of warmed crystalloid or blood to a patient over a short period of time. It is not used for medication administration. Rationale 4: This medication does not need to be administered with 0.9% normal saline.
The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings? Select all that apply. 1. Age 80 2. History of atrial fibrillation 3. Bacteremia 4. T3 spinal cord injury 5. Latex allergy
Correct Answer: 1,2 Rationale 1: Advanced age increases the risk for development of pulmonary emboli, which is one cause of obstructive shock. Rationale 2: Atrial fibrillation increases the risk for developing pulmonary emboli, which is one cause of obstructive shock. Rationale 3: Bacteremia increases a patient's risk of developing septic shock and not obstructive shock. Rationale 4: A spinal cord injury increases the risk for developing distributive shock and not obstructive shock. Rationale 5: A latex allergy increases the risk for developing distributive shock and not obstructive shock.
A patient is receiving norepinephrine 30 mcg/min for treatment of refractory shock. Which assessment findings suggest the patient is experiencing peripheral vasoconstriction from the medication? Select all that apply. 1. Decreased peripheral pulses 2. Drop in body temperature 3. Onset of paresthesias 4. Drop in blood pressure 5. Increased cardiac output
Correct Answer: 1,2,3 Rationale 1: At high doses of norepinephrine, decreased peripheral pulses indicates significant vasoconstriction. Rationale 2: At high doses of norepinephrine, a drop in body temperature indicates significant vasoconstriction. Rationale 3: At high doses of norepinephrine, paresthesias indicate significant vasoconstriction. Rationale 4: This medication does not cause a drop in blood pressure. Rationale 5: An increase in cardiac output is an expected effect of this medication and does not indicate significant vasoconstriction.
A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient? Select all that apply. 1. Administer epinephrine 1:1000 intramuscularly. 2. Apply oxygen via face mask as prescribed. 3. Provide diphenhydramine 25 mg intravenous. 4. Administer vasopressin. 5. Prepare to administer antithrombolytic agents as prescribed.
Correct Answer: 1,2,3 Rationale 1: Epinephrine produces bronchodilation, improving the respiratory status. The route of administration is initially intramuscular. Rationale 2: Supplemental oxygen is used in the treatment of anaphylactic shock. Rationale 3: Hydrogen ion blockers such as diphenhydramine may be administered to block the histamine effects. Rationale 4: Vasopressin is not used in the treatment of anaphylactic shock. Rationale 5: Antithrombolytic agents are not used in the treatment of anaphylactic shock.
During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? Select all that apply. 1. Systolic blood pressure 82 mm Hg 2. Capillary refill 10 seconds 3. Crackles bilateral lung bases 4. Heart rate 55 and regular 5. Warm dry skin
Correct Answer: 1,2,3 Rationale 1: Hypotension is a manifestation of cardiogenic shock. Rationale 2: Delayed capillary refill is a manifestation of cardiogenic shock. Rationale 3: Crackles are a manifestation of cardiogenic shock. Rationale 4: Bradycardia is not a manifestation of cardiogenic shock. Rationale 5: Warm dry skin is not a manifestation of cardiogenic shock.
The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations
Correct Answer: 1,2,3 Rationale 1: Hypotension is a manifestation of neurogenic shock because of the loss of autonomic reflexes. Rationale 2: Bradycardia occurs because of the loss of sympathetic innervation. Rationale 3: Warm dry skin occurs because of a loss of cutaneous control of sweat glands. Rationale 4: Abdominal cramping is not a manifestation of neurogenic shock. Rationale 5: Palpitations are not seen in neurogenic shock.
A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies? Select all that apply. 1. Sepsis 2. Spinal cord injury 3. Anaphylaxis 4. Hemorrhage 5. Pulmonary embolism
Correct Answer: 1,2,3 Rationale 1: One etiology of distributive shock is sepsis. Rationale 2: One etiology of distributive shock is spinal cord injury. Rationale 3: One etiology of distributive shock is anaphylaxis. Rationale 4: Hemorrhage is not an etiology of distributive shock. Rationale 5: Pulmonary embolism is not an etiology of distributive shock.
A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Select all that apply. 1. Elevated pulmonary arterial wedge pressure 2. Elevated central venous pressure 3. Elevated systemic vascular resistance index 4. Elevated mean arterial pressure 5. Elevated stroke volume
Correct Answer: 1,2,3 Rationale 1: This finding is consistent with pulmonary vascular congestion. Rationale 2: This finding is consistent with fluid volume overload. Rationale 3: This finding is consistent with pulmonary vascular congestion. Rationale 4: This finding is not consistent with cardiogenic shock. Rationale 5: This finding is not consistent with cardiogenic shock.
A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? Select all that apply. 1. Recent bee sting 2. Ingestion of drugs 3. History of latex allergy 4. Recent diagnostic imaging tests 5. Recent myocardial infarction
Correct Answer: 1,2,3,4 Rationale 1: Venoms such as bee stings can trigger anaphylactic shock. Rationale 2: Drugs can trigger anaphylactic shock. Rationale 3: Latex can trigger anaphylactic shock. Rationale 4: Contrast media for diagnostic tests can trigger anaphylactic shock. Rationale 5: Myocardial infarction is not a trigger for anaphylactic shock.
The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient? Select all that apply. 1. Dopamine 2. Norepinephrine 3. Dobutamine 4. Epinephrine 5. Phenylephrine
Correct Answer: 1,2,3,5 Rationale 1: Dopamine is commonly used in the treatment of cardiogenic shock. Rationale 2: Norepinephrine is commonly used in the treatment of cardiogenic shock. Rationale 3: Dobutamine may be used in the patient with cardiogenic shock who has an adequate blood pressure. Rationale 4: Epinephrine is not used in the treatment of cardiogenic shock. Rationale 5: Phenylephrine is a vasopressor and may be used in the patient with cardiogenic shock who is receiving dobutamine.
Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time
Correct Answer: 2 Rationale 1: An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and is not present with increased peripheral resistance and vasoconstriction. Rationale 2: Increased peripheral resistance causes the blood supply to decrease and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. Rationale 3: Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. Rationale 4: Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance.
The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication? 1. Hemorrhagic shock 2. Hypothermia 3. Sepsis 4. Cardiogenic shock
Correct Answer: 2 Rationale 1: Hemorrhagic shock is caused by a loss of cells or blood volume and is not a result of infusing fluids too quickly. Rationale 2: Hypothermia can result when providing room temperature fluids at a faster pace than the body can warm them. Rationale 3: Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid being administered. Rationale 4: Cardiogenic shock results from poor ventricular functioning, not from the temperature of the intravenous fluids being administered too rapidly.
A patient is demonstrating pulmonary edema, decreased urine output, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Anaphylactic 4. Obstructive
Correct Answer: 2 Rationale 1: Pulmonary edema would not be present in hypovolemic shock. Rationale 2: In cardiogenic shock, there is a low cardiac output, decreased urine output, and pulmonary edema. Rationale 3: Pulmonary edema would not be present in anaphylactic shock. Rationale 4: Pulmonary edema would not be present in obstructive shock
Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%
Correct Answer: 2 Rationale 1: The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not reduced. Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. Rationale 3: Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Rationale 4: SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased.
Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Select all that apply. 1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema
Correct Answer: 2,3 Rationale 1: Fluid volume overload is not an identified complication of hypovolemic shock. Rationale 2: Renal insufficiency is a serious complication because of the prerenal etiology of hypovolemia. Rationale 3: Early identification and correction of the fluid volume deficit in hypovolemic shock is necessary to prevent cerebral ischemia. Rationale 4: Although physiologic stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Rationale 5: Pulmonary edema is not an identified complication of hypovolemic shock.
What will the nurse identify as symptoms of hypovolemic shock in a patient? Select all that apply. 1. Temperature of 97.6°F (36.4°C) 2. Restlessness 3. Decrease in blood pressure of 20 mm Hg when the patient sits up 4. Capillary refill time greater than 3 seconds 5. Sinus bradycardia of 55 beats per minute
Correct Answer: 2,3,4 Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status. Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock. Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced. Rationale 5: Bradycardia is not present. The compensatory response is to increase the heart rate to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.
The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output 2. Severe constipation, causing watery diarrhea 3. Ascites 4. Syndrome of inappropriate ADH (SIADH)
Correct Answer: 3 Rationale 1: Although ECG changes reflect the effectiveness of the heart's pumping when circulating the blood, it is not a risk factor for hypovolemic shock, which reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. Rationale 2: Severe constipation does not affect the circulating blood volume. Rationale 3: Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. Rationale 4: Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema.
The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions: 1. Move quickly into the interstitial spaces and can cause third spacing 2. Stay longer to expand the intravascular space but deplete intracellular fluid levels 3. Do not stay in the intravascular space long enough to expand the circulating blood volume 4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low
Correct Answer: 3 Rationale 1: Hypotonic solutions do not cause third spacing. Rationale 2: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume. Rationale 3: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume. Rationale 4: The bore size of the needle does not affect the displacement or shifting of fluids.
A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time? 1. Limit patient movement. 2. Prepare to administer crystalloids. 3. Administer phenylephrine as prescribed. 4. Administer atropine as prescribed.
Correct Answer: 4 Rationale 1: Limiting movement will not correct bradycardia in the patient with neurogenic shock. Rationale 2: Crystalloids are used to correct vasodilation. Rationale 3: Phenylephrine is used in the patient with neurogenic shock to correct hypotension. Rationale 4: Bradycardia in neurogenic shock is corrected by the administration of atropine at the dose of 0.5 to 1.0 mg intravenous every 5 minutes to a total dose of 3 mg.
The client diagnosed with septicemia is receiving a broad spectrum antibiotic. Which laboratory data require the nurse to notify the health care provider? a. The client's potassium level is 3.8mEq/l b. The urine culture indicates high sensitivity to the antibiotic c. The clients pulse oximeter reading is 94% d. The culture and sensitivity is resistant to the client's antibiotic
D A sensitivity report indicating a resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organism and the HCP needs to be notified so the antibiotic can be changed.
1. What is the key factor in describing any type of shock? A. Hypoxemia B. Hypotension C. Vascular Collapse D. Inadequate tissue perfusion
D Although all of these factors may be present, regardless of the cause, the end result is inadequate supply of oxygen and nutrients to body cells from inadequate tissue perfusion.
As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic changes occur related to the increased angiotensin II? a. Vasodilation b. Decreased blood pressure and CO c. Aldosterone release results in sodium and water excretion d. Antidiuretic hormone (ADH) release increases water reabsorption
D Angiotensin II vasoconstricts both arteries and veins, which increases BP. It stimulates aldosterone release form the adrenal cortex which results in sodium and water reabsorption and potassium excretion by the kidneys. This increased sodium raises serum osmolality and stimulates the pituitary gland to release antidiuretic hormone (ADH) which increases water reabsorption, which further increases blood volume, leading to increase BP and CO.
Progressive tissue hypoxia leading to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contribute to this increasing tissue hypoxia? a. Arterial constriction causes decreased perfusion b. Vasoconstriction decreased blood flow to pulmonary capillaries c. Increased capillary permeability and profound vasoconstriction cause increased hydrostatic pressure d. Decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells
D Decrease myocardial perfusion leads to dysrhythmias and myocardial ischemia, further decreasing CO and oxygen delivery to cells. The kidneys RAAS activation causes arteriolar constriction that decreases perfusion.. In the lungs vasoconstriction of arterioles decreases blood flow and a ventilation-perfusion mismatch occurs. Areas of the lung that are oxygenated are not perfused because of the decrease blood flow resulting in hypoxemia and decrease oxygen for cells. Increase capillary permeability and vasoconstriction cause increased hydrostatic pressure that contributes to the fluid shifting to interstitial spaces.
Priority Decision: A patient with acute pancreatitis is experiencing hypovolemic shock. Which initial orders for the patient will the nurse implement first? a. Start 1000ml of normal saline at 500ml/hr. b. Obtain blood cultures before starting IV antibiotics. c. Draw blood for hematology and coagulation factors. d. Administer high-flow oxygen (100%) with a non-rebreather mask
D In every type of shock there is a deficiency of oxygen to the cells and high flow oxygen therapy is indicated. Fluids would be started next, blood cultures would be done before any antibiotic and lab specimens then could be drawn.