Chapter 28 Fluid balance (hyper & hypo volemic shock)

29.1 The young client has a history of multiple allergies, and the physician prescribed epinephrine (EpiPen) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." What is the best response by the nurse? 1. "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." 2. "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." 3. "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure." 4. "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure."

Answer: 1 "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." Rationale: Obvious bleeding suggests hypovolemic shock, trauma to the brain or spinal cord suggests neurogenic shock, inadequate cardiac output would suggest cardiogenic shock, a recent infection may indicate septic shock, and a history of allergies with a sudden onset of symptoms may suggest anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of shock. Liver failure is not a type of shock.

29.14 The client comes to the emergency department with a severe allergic reaction to peanuts, and is in serious respiratory distress. The client's spouse tells the nurse that the client has a known hypersensitivity to epinephrine (Adrenalin). What is the best response by the nurse? 1. "This is a life-threatening situation; a prior hypersensitivity is not an absolute contraindication." 2. "I will let the physician know about this immediately; we will need to choose an alternative medication." 3. "This is a problem; we will need to use IV diphenhydramine (Benadryl)." 4. "I'm not sure what we can use then. Do you know what has been used before with this allergic response?"

Answer: 1 "This is a life-threatening situation; a prior hypersensitivity is not an absolute contraindication." Rationale: Although epinephrine is contraindicated for known hypersensitivity to the drug, in life-threatening situations there are no absolute contraindications to its use. Diphenhydramine (Benadryl) may not be the best choice, and the nurse must speak with conviction to decrease anxiety in the patient and spouse.

29.7 A graduate nurse abruptly discontinues the intravenous (IV) norepinephrine (Levarterenol) once it has infused into the client. What is the priority action of the more experienced nurse? 1. Assess the client's blood pressure. 2. Notify the physician. 3. Administer oxygen via a rebreather mask. 4. Obtain an oxygen saturation reading with a pulse oximeter.

Answer: 1 Assess the client's blood pressure. Rationale: Discontinuation of vasopressor therapy is always gradual, due to the possibility of rebound hypotension and undesirable cardiac effects, so the nurse should immediately assess the client's blood pressure. The nurse will notify the physician, but the physician will want to know what the blood pressure is, so plan to assess blood pressure first. There is no indication to administer oxygen at this point. There is no indication to obtain an oxygen saturation percentage at this point.

29.9 The client has experienced hypovolemic shock as a result of severe burns. The physician orders a low dose of dopamine (Inotropin). What is the best evaluation by the nurse? 1. Urinary output of at least 50 mL/hour. 2. Increased cardiac output. 3. Vasoconstriction and increased blood pressure. 4. Stabilization of fluid loss.

Answer: 1 Urinary output of at least 50 mL/hour. Rationale: At low doses, dopamine (Inotropin) stimulates dopaminergic receptors, especially in the kidneys, leading to vasodilation and an increased blood flow through the kidneys. Increased cardiac output occurs with high, not low, doses of dopamine (Inotropin) when beta1-adrenergic receptors are stimulated. Vasoconstriction and increased blood pressure occurs with high, not low, doses of dopamine (Inotropin) when alpha-adrenergic receptors are stimulated. Dopamine (Inotropin) does not prevent or stabilize fluid loss.

29.3 The client comes to the emergency department with a severely infected pressure ulcer on the back. The client is in septic shock. The physician orders norepinephrine (Levophed) IV. Prioritize the nursing interventions for this client. 1. Connect the client to a cardiac monitor and pulse oximeter. 2. Assess the client's blood pressure. 3. Prepare for debridement of the pressure ulcer. 4. Administer oxygen. 5. Maintain a patient airway.

Answer: 1, 2, 3, 4, 5

29.10 The nurse works in a summer camp for children. One of the children says she was bitten by several wasps. The nurse plans to inject the child with epinephrine (EpiPen) if which symptoms are present? Select all that apply. 1. The child is restless and confused. 2. The child's skin feels warm and dry. 3. The child is thirsty. 4. The child's skin feels cold and clammy. 5. The child is hyperactive and hyperverbal.

Answer: 1, 3, 4 Rationale: General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock. In shock, the skin is cold and clammy, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.

29.4 The client is recovering from hypovolemic shock. The nurse hangs a bag of normal human serum albumin (Albutein) and educates the client about this fluid. The nurse evaluates that learning has occurred when the client makes which statement? 1. "It is a liquid that has electrolytes in it to pull water into my blood vessels." 2. "It is a protein that pulls water into my blood vessels." 3. "It is a protein that causes my kidneys to conserve fluid." 4. "It is a super-concentrated salt solution that helps me conserve body fluid."

Answer: 2 "It is a protein that pulls water into my blood vessels." Rationale: Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Normal human serum albumin (Albutein) does not act on the kidneys. Normal human serum albumin is not a concentrated saline solution.

29.12 The physician has prescribed phenylephrine (Neo-Synephrine) for an elderly client. What is an important nursing assessment prior to administration of this drug? 1. A history of dizziness. 2. A history of narrow angle glaucoma. 3. A history of diabetes mellitus, type I. 4. A history of human immunodeficiency virus (HIV) infection.

Answer: 2 A history of narrow angle glaucoma. Rationale: Vasoconstrictors may increase intraocular pressure, so the nurse should assess for narrow angle glaucoma. Dizziness is a general symptom and not specific to this drug. Diabetes mellitus, type I is not adversely affected by administration of a vasoconstrictor drug. Human immunodeficiency virus (HIV) infection is not adversely affected by administration of a vasoconstrictor drug.

29.15 The client is receiving norepinephrine (Levophed). When monitoring the client's blood pressure, the nurse notes a pressure of 230/120 mm/Hg. What is the priority nursing action? 1. Notify the physician. 2. Stop the infusion. 3. Slow the rate of the infusion until the physician assesses the client. 4. Assess the client for signs/symptoms of a stroke.

Answer: 2 Stop the infusion Rationale: Discontinuing the infusion results in a reversal of adverse effects such as hypertension. The nurse would notify the physician, but this should occur after discontinuing the infusion. The infusion must be stopped, not slowed, before the client experiences the adverse effects of extreme hypertension.

29.6 The client is receiving human serum albumin (Albutein) as treatment for shock. What is a priority assessment by the nurse? 1. Auscultate for an absence of breath sounds in the lower lobes. 2. Auscultate breath sounds for hyper-resonance. 3. Auscultate breath sounds for crackles. 4. Auscultate breath sounds for inspiratory stridor.

Answer: 3 Auscultate breath sounds for crackles. Rationale: Because human serum albumin (Albutein) pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema. Hyper-resonance is assessed by percussion, not auscultation. Stridor is auscultated with airway obstruction, not pulmonary edema.

29.2 The client comes to the emergency department after suffering a bilateral traumatic amputation of his lower extremities. The physician orders normal serum albumin (Albuminar). The client goes into shock. What will the best nursing assessment of this client reveal? 1. B/P: 130/88 mm/Hg, P: 90, bounding, R: 32, and shallow. 2. B/P: 50/0 mm/Hg, P: 126, weak and thready, R: 14, and shallow. 3. B/P: 80/20 mm/Hg, P: 122, weak and thready, R: 28, and shallow. 4. B/P: 140/90 mm/Hg, P: 46, weak and irregular, R: 24, and shallow.

Answer: 3 B/P: 80/20 mm/Hg, P: 122, weak and thready, R: 28, and shallow. Rationale: The central problem with hypovolemic shock is the inability of the cardiovascular system to send sufficient blood to the vital organs, with the heart and brain being affected early in the progression of the disease. Assessing the client's cardiovascular status will result in a blood pressure that is low, a heart rate that may be rapid with a weak, thready pulse, and breathing that is rapid and shallow. A client in shock will have a low blood pressure and a rapid, weak, not bounding, pulse. A client in shock will have rapid respirations, a respiratory rate of 14 is considered normal. A client in shock will have a low blood pressure; the heart rate will be rapid, not slowed.

29.8 The physician orders dopamine (Dopastat) intravenous (IV) for the client in shock. What is a priority plan of the nurse with regard to administration of this drug? 1. Have epinephrine (Adrenalin) available in the room. 2. Have naltrexone (Revia) available in the room. 3. Have phentolamine (Regitine) available in the room. 4. Have flumazenil (Romazicon) available in the room.

Answer: 3 Have phentolamine (Regitine) available in the room. Rationale: Extravasation of dopamine (Dopastat) can cause severe, localized vasoconstriction resulting in tissue necrosis. The antidote for this is phentolamine (Regitine). Epinephrine is used for anaphylaxis. Naltrexone (Revia) is used for opiate overdose. Flumazenil (Romazicon) is used for benzodiazepine overdose.

29.5 The client is in shock with a blood pressure of 60/20 mm/Hg. The physician orders isoproterenol (Isuprel) intra-venously (IV). The family is quite anxious and asks what "that liquid" is for. What is the best response of the nurse? 1. "It is called a vasopressor and will help the kidneys increase and maintain blood pressure." 2. "This drug is a vasopressor and helps the heart beat more effectively, which will increase blood pressure." 3. "Vasopressor drugs act on the renin-angiotension system and thus increase blood pressure." 4. "This drug is a vasopressor and will help stabilize blood pressure by making the blood vessels smaller."

Answer: 4 "This drug is a vasopressor and will help stabilize blood pressure by making the blood vessels smaller." Rationale: In early shock, the body compensates for the fall in blood pressure by activating the sympathetic nervous system. The body's ability is limited, so sympathomimetic vasoconstrictors, known as vasopressors, have been used to stabilize blood pressure in shock clients. Vasopressors do not act on the kidneys. Vasopressors do not increase cardiac contractility. Vasopressors do not affect the renin-angiotension system.

29.13 The client will be receiving dopamine (Dopastat). What equipment will the nurse plan to obtain prior to infusion of this drug? 1. Pulse oximeter 2. Oxygen cannula 3. Sequential compression devices 4. Intravenous (IV) pump

Answer: 4 Intravenous (IV) pump Rationale: Inotropic medications are administered as a continuous infusion based on micrograms per kilograms per minute. Always infuse these medications via an intravenous (IV) pump. A pulse oximeter is an important piece of equipment, but not as important as an intravenous (IV) pump. An oxygen cannula is an important piece of equipment, but not as important as an intravenous (IV) pump. Sequential compression devices are important pieces of equipment, but not as important as an intravenous (IV) pump.

29.11 The client is receiving normal serum albumin (Albuminar). What will be a priority outcome with this client? 1. The client will remain alert and oriented. 2. The client will be normotensive, not hypertensive. 3. The client will be free of a rash. 4. The client will experience adequate breathing patterns.

Answer: 4 The client will experience adequate breathing patterns. Rationale: Albumin is a natural blood product and allergic reactions are possible. A serious symptom of an allergic reaction is dyspnea or difficulty breathing. Alertness and orientation are important, but are not priority outcomes. Hypotension, not hypertension, is a possible adverse outcome with normal serum albumin (Albuminar). A rash is a possible adverse outcome, but is not as much of a priority as dyspnea.

29. 21 The mechanism of action of norepinephrine is to: a. Produce vasoconstriction. b. Cause increased blood flow. c. Decrease cardiac output. d. Increase heart rate.

Answer: A Produce vasoconstriction.

29.20 Examples of vasoconstrictors used to treat shock include all of the following except: a. Propranolol (Inderal). b. Norepinephrine (Levophed). c. Mephentermine (Wyamine). d. Phenylephrine (Neo-synephrine).

Answer: A Propranolol (Inderal).

29.17 A client with cardiogenic shock would exhibit which of the following symptoms? a. Restlessness and anxiety b. Bradycardia c. Tachycardia and low blood pressure d. Low temperature

Answer: C Tachycardia and low blood pressure

29.18 What would the expected first treatment of shock be? a. Start an intravenous line. b. Take the blood pressure. c. Assess level of consciousness. d. Maintain the airway.

Answer: D Maintain the airway.

29.19 Colloids differ from crystalloids in that: a. They contain electrolytes. b. They readily leave the blood and enter cells. c. They promote urine output. d. They are too large to cross membranes.

Answer: D They are too large to cross membranes.

29.16 Hypovolemic shock is different from neurogenic shock in that it relates to: a. Inadequate cardiac output. b. An infectious process. c. A brain or spinal cord trauma. d. Volume depletion.

Answer: D Volume depletion.