EAQ Shock, Sepsis, and Multiple Organ Dysfunction

The nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response would the nurse expect? A. Hypokalemia B. Metabolic acidosis C. Respiratory alkalosis D. Decreased carbon dioxide level

B. Metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

Which change in the client's lab results indicates that the client is in septic shock? A. Blood glucose of 80 mg/dL B. An increased serum lactate level C. An increased neutrophil level D. A white blood count (WBC) of 5000 cells/µL

B. An increased serum lactate level The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count >12,000 cells/µL or <4,000 cells/µL, and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 mg/dL and >150 mg/dL. Blood glucose levels of 70 mg/dL to 100 mg/dL are considered normal.

A client undergoes a subtotal gastrectomy. After surgery the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. One, some, or all responses may be correct. 1. Oliguria 2. Bradypnea 3. Diaphoresis 4. Tachycardia 5. Hypertension

1. Oliguria 3. Diaphoresis 4. Tachycardia Decreased blood volume leads to decreased glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, thereby decreasing urinary output. Diaphoresis and tachycardia occur because of the sympathetic nervous system-mediated response. Respirations become rapid and shallow, not slow, because of the sympathetic nervous system-mediated response. Hypotension, not hypertension, is the response to a decrease in circulating blood volume.

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and has hypovolemic shock. Which site(s) would be used to obtain the client's pulse rate? Select all that apply. One, some, or all responses may be correct. 1. Apical 2. Carotid 3. Brachial 4. Femoral 5. Popliteal

2. Carotid 4. Femoral Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. The apical pulse may not be palpable in a client with hypovolemic shock. The popliteal site is used to assess the status of the circulation in the lower leg.

A health care provider in the emergency department identifies that a client is in cardiogenic shock. Which type of medication is indicated for management of this condition? A. Loop diuretic B. Cardiac glycoside C. Sympathomimetic D. Alpha-adrenergic blocker

C. Sympathomimetic Sympathomimetics are vasopressors that induce arterial constriction, which increases venous return and cardiac output. Diuretics promote excretion of fluid, which is not indicated. Cardiac glycosides slow and strengthen the heartbeat; they do not increase the blood pressure and may decrease it. Alpha-adrenergic blockers decrease peripheral resistance, resulting in a decreased blood pressure.

Which priority action would the nurse perform when caring for a client with suspected anaphylaxis? A. Obtain full set of vital signs. B. Assess airway and oxygenation. C. Determine level of consciousness D. Notify the client's health care provider

B. Assess airway and oxygenation The first action the nurse will perform when caring for a client with suspected anaphylaxis is to assess respiratory status including airway and oxygenation. Next the nurse will notify the Rapid Response Team. After the airway and oxygenation have been assessed, the nurse will obtain vital signs, assess level of consciousness, and notify the health care provider.

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. Which signs would the nurse expect when assessing the client? Select all that apply. One, some, or all responses may be correct. 1. Fever 2. Tachypnea 3. Hypertension 4. Abdominal rigidity 5. Increased bowel sounds

1. Fever 2. Tachypnea 4. Abdominal rigidity The metabolic rate will be increased, and the temperature-regulating center in the hypothalamus resets to a higher-than-usual body temperature because of the influence of pyrogenic substances related to the peritonitis. Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. With increased intra-abdominal pressure, the abdominal wall will become rigid and tender. Hypovolemia and hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intra-abdominal pressure.

After administering epinephrine to a client experiencing an anaphylactic reaction, which second-line medications would the nurse prepare to administer? Select all that apply. One, some, or all responses may be correct. 1. Dopamine 2. Norepinephrine 3. Dexamethazone 4. Diphenhydramine hydrochloride 5. Hydrocortisone sodium succinate

3. Dexamethazone 4. Diphenhydramine hydrochloride 5. Hydrocortisone sodium succinate Dexamethasone is a corticosteroid that is a second-line medication used in the treatment of anaphylaxis. Diphenhydramine hydrochloride is an antihistamine that is a second-line medication used in the treatment of anaphylaxis. Hydrocortisone sodium succinate is a corticosteroid that is a second-line medication used in the treatment of anaphylaxis. Dopamine and norepinephrine are vasopressor medications and are considered support medications in the treatment of anaphylaxis.

Which action will the nurse take first when treating a client who is having an anaphylactic reaction? A. Give epinephrine 0.5 mg intramuscularly. B. Infuse normal saline 500 mL intravenously C. Inject methylprednisolone 120 mg intravenously D. Administer oxygen through a non-rebreather mask

A. Give epinephrine 0.5 mg intramuscularly. The initial action for anaphylaxis would be administration of epinephrine to correct bronchoconstriction and arterial dilation. The other actions are also appropriate, but evidence indicates that successful treatment of anaphylaxis requires early administration of epinephrine. Normal saline is given to correct hypotension caused by arterial dilation. Use of steroids such as methylprednisolone decreases the inappropriate inflammatory response that causes symptoms of anaphylaxis. Administration of high levels of oxygen is needed to correct hypoxemia but will not be effective until bronchoconstriction is corrected through epinephrine administration.

When a client with hypovolemic shock has a hematocrit value of 25%, which fluid therapy will the nurse prepare to infuse? A. Lactated Ringer solution B. Human serum albumin 5% C. Packed red blood cells D. High molecular weight dextran

C. Packed red blood cells Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. The other three fluids will increase volume, but will not improve the oxygen-carrying capacity of the blood. Lactated Ringer solution does not increase the oxygen-carrying capacity of the blood. Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.

When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion? A. Implanted port B. Midline catheter C. 18-gauge peripheral venous catheter D. Peripherally inserted central catheter (PICC) line

D. Peripherally inserted central catheter (PICC) line Norepinephrine is a vesicant and can cause tissue necrosis if it infiltrates into the intradermal or subcutaneous tissues. It is best infused through a central line, such as a PICC line. Implanted ports are also central lines, used mainly for chemotherapy, but require specialized needles and staff who are trained in accessing the port. Midline catheters are peripherally inserted in the antecubital area or upper arm and are not recommended for infusion of vesicants because large amounts of fluid may escape into the subcutaneous tissues before the infiltration is noted. Infiltration of fluids occurs more frequently when fluids are infused through the smaller and more fragile peripheral veins.

When the nurse is caring for a client who has cardiogenic shock, which clinical manifestations will be expected? Select all that apply. One, some, or all responses may be correct. 1. Rapid pulse 2. Deep respirations 3. Warm, flushed skin 4. Increased BP 5. Decreased urinary output

1. Rapid pulse 5. Decreased urinary output The heart rate increases (tachycardia) to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure.

When assessing a client with cardiogenic shock, which clinical manifestations will the nurse expect to find? Select all that apply. One, some, or all responses may be correct. 1. Polyuria 2. Dyspnea 3. Diaphoresis 4. Tachycardia 5. Hypertension

2. Dyspnea 3. Diaphoresis 4. Tachycardia Shortness of breath and an increase in the respiratory rate occur with cardiogenic shock. Cold, clammy (diaphoresis) skin occurs because of vasoconstriction associated with stimulation of the sympathetic nervous system. The heart rate increases (tachycardia) as the heart attempts to maintain cardiac output and circulating blood volume. A decrease in circulation of blood to the kidneys results in oliguria, not polyuria. Hypotension, not hypertension, is a sign of cardiogenic shock; the systolic reading is often below 90 mm Hg.

When a family member of a client with cardiogenic shock asks the nurse for more information about the condition, how would the nurse describe cardiogenic shock? A. An irreversible phenomenon B. A failure of the circulatory pump C. Usually a fleeting reaction to tissue injury D. Generally caused by decreased blood volume

B. A failure of the circulatory pump In cardiogenic shock, ineffective cardiac pumping or contraction is the cause of the poor peripheral circulation. In the early stages, cardiogenic shock is reversible. Cardiogenic shock indicates a severe and usually chronic decrease in cardiac function and is not a fleeting reaction to tissue injury (such as might occur with anaphylactic shock). Cardiogenic shock is caused by poor cardiac function and results in hypervolemia. A decrease in blood volume would cause hypovolemic shock.

Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock? A. Oliguria B. Crackles C. Dyspnea D. Bounding pulse

A. Oliguria Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased renal perfusion secondary to a decreased circulating blood volume. Crackles are associated with pulmonary edema caused by cardiogenic shock, not hypovolemic shock. Dyspnea may be associated with hypervolemia, not hypovolemia, and also with pulmonary edema and respiratory disorders. Bounding pulse will occur with hypervolemia.

Which nursing intervention would prevent septic shock in the hospitalized client? A. Maintain the client in a normothermic state B. Administer blood products to replace fluid losses C. Use aseptic technique during all invasive procedures D. Keep the critically ill client immobilized to reduce metabolic demands

C. Use aseptic technique during all invasive procedures Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.