Cardiogenic Shock (med-surg)
The primary nurse is preparing to administer dobutamine to a client diagnosed with cardiogenic shock. Which action by the primary nurse warrants intervention by the charge nurse? 1. The primary nurse is administering the dobutamine drip via gravity. 2. The primary nurse attaches a urometer to the client's Foley catheter. 3. The primary nurse applies a pulse oximeter to the client's fi nger. 4. The primary nurse checks the client for any medication allergies.
1 1. An infusion pump should be used when administering dobutamine (Dobutrex), a beta1-adrenergic agonist, because an overdose, which could occur if a drip via gravity is used, could cause the client's death. This action by the primary nurse would warrant immediate intervention by the charge nurse. 2. A urometer is a plastic triangular container that can be attached to a Foley catheter and allows the nurse to obtain hourly urinary outputs. This action would not require intervention by the charge nurse. 3. Monitoring the client's peripheral oxy- gen saturation would be appropriate for a client in cardiogenic shock; therefore, this action would not warrant intervention by the charge nurse. 4. The nurse should always check the client for any types of allergies; therefore, this action would not warrant intervention by the charge nurse.
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 1. There are many types of shock, but the one common intervention which should be done first in all types of shock is to estab- lish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock. 2. This blood pressure does not require dopa- mine; 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 output, but it is not the first intervention.
The nurse is preparing to administer dopamine to a client diagnosed with cardiogenic shock. Which intervention should the nurse implement? Select all that apply. 1. Ensure the client is on a cardiac monitor. 2. Monitor the blood pressure every 15 minutes. 3. Evaluate the intake and output every hour. 4. Instruct the client to report burning at the IV site. 5. Assess the client's neurological status every hour.
1, 3, 4 1. Clients must be connected to a cardiac monitor prior to and during the infusion of dopamine, a beta and alpha agonist, and other cardiotonic drugs. The client in cardiogenic shock will be in the inten- sive care department. 2. Dopamine, a beta and alpha agonist, is administered to increase the blood pressure, and the blood pressure must be monitored every 5 to 15 minutes. 3. The client's urinary output should be monitored hourly to ensure the client has at least 30 mL of urine output an hour. 4. Extravasation of dopamine, a beta and alpha agonist, causes severe, localized vasocon- striction, resulting in a slough of the tissue and tissue necrosis. The client should report burning at the IV site immediately. 5. Septic shock does not specifi cally affect the neurological system; therefore, the nurse does not need to assess this system every hour, just every shift.
The nurse is caring for a client diagnosed with cardiogenic shock who is receiving a dopamine drip. Which interventions should the nurse implement? Select all that apply. 1. Aspirate the injection site to avoid injecting directly into the vein. 2. Do not administer any alkaline solutions in the same tubing as dopamine. 3. Assess the client's lung sounds, vital signs, and hemodynamic parameters. 4. Ask if the client has a living will or durable power of attorney for health care. 5. Administer the dopamine via a Y-tubing along with normal saline (0.9%).
2, 3, 4 1. This would be appropriate when injecting medications intramuscularly or subcu- taneously, but dopamine drip, a sym- pathomimetic, can only be administered intravenously. 2. Sympathomimetics are incompatible with sodium bicarbonate or alkaline solutions. 3. The client in hypovolemic shock is in critical condition, and a thorough assessment must be completed on the client frequently. 4. This intervention is not specifi c for the dopamine drip, a sympathomimetic, but a client in cardiogenic shock taking dopamine is in critical condition. An advance directive would be an appropri- ate intervention for this client. 5. Dopamine is not administered via Y-tubing. Blood and blood products are administered via Y-tubing.
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 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. 3. Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can 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 client diagnosed with cardiogenic shock is receiving dopamine. The peripheral IV site becomes infiltrated. Which intervention should the nurse implement? 1. Assess the client's blood pressure and apical pulse. 2. Elevate the arm and apply ice to the infiltrated area. 3. Inject phentolamine at the site of infiltration. 4. Discontinue the IV and take no other action.
3 1. The nurse should address the infi ltrated site because of the toxic effects of the med- ication in the tissue. The blood pressure reading and apical pulse rate will not help the infi ltrated site. 2. This is not the appropriate action to take when dopamine, a beta and alpha agonist, infi ltrates. 3. Extravasation of dopamine, a beta and alpha agonist, causes severe, localized vasoconstriction, resulting in a slough of the tissue and tissue necrosis if not reversed with the antidote phentol- amine (Regitine) injections at the site of the infi ltration. 4. The IV should be discontinued, but the nurse must take further action or the IV site may have tissue necrosis.
Which of the following are assessment findings in a client experiencing shock? Select all that apply. 1. Bradycardia 2. Oliguria 3. Cool, clammy skin 4. Increased blood pressure 5. Weak or absent pulse
3. Cool, clammy skin Some typical findings of shock include decreased blood pressure, tachycardia (and a weak thready pulse), cool, clammy skin, and oliguria. 5. Weak or absent pulse A weak or absent pulse is an expected finding in the client with shock, due to the lack of circulating blood. 2. Oliguria The client in shock is not making urine, so oliguria is present.
The client diagnosed with cardiogenic shock is receiving norepinephrine. Which priority intervention should the nurse implement? 1. Do not abruptly discontinue the medication. 2. Administer medication on an infusion pump. 3. Check the client's creatinine and BUN levels. 4. Monitor the client's blood pressure continuously.
4 1. Norepinephrine (Levophed), a sympatho- mimetic, must be tapered, but this is not the priority nursing intervention when adminis- tering this medication. Caring for the client is always priority. 2. Administering medication on an infu- sion pump is important, but the priority intervention is caring for the client, not a machine. 3. The nurse should check the client's renal status, but the priority nursing intervention is assessing the data for which the client is receiving the medication. 4. Norepinephrine (Levophed), a sympath- omimetic, is a powerful vasoconstrictor; therefore, continuous monitoring of the blood pressure is required to avoid hypertension.
A client who has been diagnosed with obstructive shock due to cardiac tamponade is demonstrating pulsus paradoxus upon assessment. Which best describes this abnormality? Alternating weak and strong pulses upon palpation The pulse on the right side of the body is more intense than on the left side of the body Rapid pulse when the client breathes in but slowing pulse when the client breathes out A decrease in systolic blood pressure by more than 10mmHg during inspiration
A decrease in systolic blood pressure by more than 10mmHg during inspiration
Cardiogenic shock usually occurs from which of the following conditions? Acute blood loss Acute myocardial infarction Hypovolemia Spinal cord injury
Acute myocardial infarction Cardiogenic shock is decreased cardiac output and evidence of tissue hypoxia, when there is still adequate intravascular volume. Cardiogenic shock usually occurs from an acute myocardial infarction or dysrhythmia.
In which situation would the administration of a loop diuretic like furosemide (Lasix) be most appropriate? Cirrhosis Anuria Pulmonary edema Hyponatremia
Pulmonary edema Lasix is a loop diuretic that is used to release excess salt into the urine, instead of it being reabsorbed into the bloodstream. It is most commonly used in conditions of excess fluid, such as pulmonary edema, hypertension, heart failure, or renal disease.
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 bowel sounds f. Tachypnea and tachycardia
a, c, f. In the compensatory stage of shock the patient's skin will be pale and cool (α-adrenergic stimulation). There may also be a change in level of consciousness, but the person will be responsive, the BP will be lower than baseline, bowel sounds will be hypoactive (α-adrenergic stimulation), and tachypnea and tachycardia (β-adrenergic stimulation) will occur. Unresponsiveness and moist crackles in the lungs occur in the progressive stage of shock.
What abnormal finding should the nurse expect to find in early compensatory shock? a. Metabolic acidosis b. Increased serum sodium c. Decreased blood glucose d. Increased serum potassium
b. In early compensatory shock, activation of the renin-angiotensin-aldosterone system stimulates the release of aldosterone, which causes sodium reabsorption and potassium excretion by the kidney, elevating serum sodium levels and decreasing serum potassium levels. Metabolic acidosis does not occur until the progressive stage of shock. At this stage compensatory mechanisms become ineffective and anaerobic cellular metabolism causes lactic acid production. Blood glucose levels are elevated during the compensatory stage of shock in response to catecholamine stimulation of the liver, which releases its glycogen stores in the form of glucose.
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 the 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.
What should the nurse assess the patient for during administration of IV norepinephrine (Levophed)? a. Hypotension b. Marked diuresis c. Metabolic alkalosis d. Decreased tissue perfusion
d. As a vasopressor, norepinephrine may cause severe vasoconstriction, which would further decrease tissue perfusion, especially if fluid replacement is inadequate. Vasopressors generally cause hypertension, reflex bradycardia, and decreased urine output because of decreased renal blood flow. They do not directly affect acid-base balance.
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. Coronary artery constriction causes decreased perfusion. b. Cardiac vasoconstriction decreases 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. Decreased myocardial perfusion leads to dysrhythmias and myocardial ischemia, further decreasing CO and oxygen delivery to cells. The kidney's renin-angiotensin-aldosterone system activation causes arteriolar constriction that decreases perfusion. In the lung, 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 decreased blood flow, resulting in hypoxemia and decreased oxygen for cells. Increased capillary permeability and vasoconstriction cause increased hydrostatic pressure that contributes to the fluid shifting to interstitial spaces, but this is not a change in the heart.