Lippincott Q & A Client is in Shock

106. Which of the following is the most important goal of nursing care for a client who is in shock? ■ 1. Manage fluid overload. ■ 2. Manage increased cardiac output. ■ 3. Manage inadequate tissue perfusion. ■ 4. Manage vasoconstriction of vascular beds.

106. 3. Nursing interventions and collaborative management are focused on correcting and main- taining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

107. Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss? ■ 1. Pulse rate less than 60 bpm. ■ 2. Respiratory rate of 4 breaths/minute. ■ 3. Pupils unequally dilated. ■ 4. Systolic blood pressure less than 90 mm Hg.

107. 4. Typical signs and symptoms of hypov- olemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachy- cardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possi- bly to a previous history of eye injury.

118. Which of the following is an indication of a complication of septic shock? ■ 1. Anaphylaxis. ■ 2. Acute respiratory distress syndrome (ARDS). ■ 3. Chronic obstructive pulmonary disease (COPD). ■ 4. Mitral valve prolapse.

118. 2. ARDS is a complication associated with septic shock. ARDS causes respiratory failure and may lead to death, even after the client has recovered from shock. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruc- tion of bronchial airflow and involves chronic bron- chitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.

117. Which nursing intervention is most important in preventing septic shock? 1. Administering I.V. fluid replacement therapy as ordered. 2. Obtaining vital signs every 4 hours for all clients. 3. Monitoring red blood cell counts for elevation. 4. Maintaining asepsis of indwelling urinary catheters.

394 The Nursing Care of Adults with Medical and Surgical Health Problems hemoglobin level in the low range of normal and a hematocrit reflecting fluid volume loss. Getting the I.V. line started is crucial so that this client can receive FFP immediately. FFP contains concentrated clotting factors and provides an immediate reversal of the prolonged INR. Vitamin K 2.5 mg P.O. should be given next because it reverses the warfarin by returning the PT to normal values. However, the reversal process occurs over 1 to 2 hours. The other orders should be completed after these initial orders are in progress. CN: Pharmacological and parenteral therapies; CL: Synthesize 114. 2. Nursing interventions to provide warmth and rest and minimize anxiety decrease the body's need for oxygen and nutrients. This is important for a client who has lost 500 mL or a unit of blood in a short period from a gastric hemorrhage. If the client has been stabilized, the fluid and electrolyte balance has already been established for the present. The comfort of the client and family is always impor- tant and is actually accomplished while the client's oxygen consumption is being minimized, which is a priority and the primary rationale. These nursing interventions are not specific to the prevention of infection. CN: Physiological adaptation; CL: Apply 115. 2. Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confu- sion; decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock. CN: Physiological adaptation; CL: Analyze 116. 1. The nurse monitors the blood levels of antibiotics, white blood cells, serum creatinine, and blood urea nitrogen because of the decreased perfu- sion to the kidneys, which are responsible for filter- ing out the Rocephin. It is possible that the clear- ance of the antibiotic has been decreased enough to cause toxicity. Increased levels of these laboratory values should be reported to the physician imme- diately. A spinal fluid analysis is done to examine cerebral spinal fluid, but there is no indication of central nervous system involvement in this case. Arterial blood gases are used to determine actual blood gas levels and assess acid-base balance. Serum osmolality is used to monitor fluid and electrolyte balance. CN: Pharmacological and parenteral therapies; CL: Analyze 117. 4. Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Prevent- ing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Adminis- tering I.V. fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

108. Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate? 1. Urine output greater than 30 mL/hour. 2. Systolic blood pressure greater than 110 mm Hg. 3. Diastolic blood pressure greater than 90 mm Hg. 4. Respiratory rate of 20 breaths/minute.

108. 1. Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consis- tently greater than 35 mL/hour. Blood pressure is a more accurate reflection of the adequacy of vasocon- striction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.

109. Which of the following is a risk factor for hypovolemic shock? ■ 1. Hemorrhage. ■ 2. Antigen-antibody reaction. ■ 3. Gram-negative bacteria. ■ 4. Vasodilation.

109. 1. Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sym- pathetic tone (vasodilation) occurs in neurogenic shock.

110. Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution? ■ 1. Fluid balance. ■ 2. Anaphylactic reaction. ■ 3. Pain. ■ 4. Altered level of consciousness.

110. 2. The client who is receiving a blood product requires astute assessment for signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or glot- tal edema, and shortness of breath. If such a reac- tion occurs, the nurse should stop the transfusion immediately, but leave the I.V. line intact, and notify the physician. Usually, an antihistamine such as diphenhydramine hydrochloride (Benadryl) is administered. Epinephrine and corticosteroids may be administered in severe reactions. Fluid balance is not an immediate concern during the blood admin- istration. The administration should not cause pain unless it is extravasating out of the vein, in which case the I.V. administration should be stopped. Administration of a unit of blood should not affect the level of consciousness.

111. The client who does not respond adequately to fluid replacement has an order for an I.V. infusion of dopamine hydrochloride at 5 μg/kg/minute. To determine that the drug is having the desired effect, the nurse should assess the client for: ■ 1. Increased renal and mesenteric blood flow. ■ 2. Increased cardiac output. ■ 3. Vasoconstriction. ■ 4. Reduced preload and afterload.

111. 2. At medium doses (4 to 8 μg/kg/minute), dopamine hydrochloride slightly increases the heart rate and improves contractility to increase cardiac output and improve tissue perfusion. When given at low doses (0.5 to 3.0 μg/kg/minute), dopamine increases renal and mesenteric blood flow. At high doses (8 to 10 μg/kg/minute), dopamine produces vasoconstriction, which is an undesirable effect. Dopamine is not given to affect preload and after- load.

112. A client is receiving dopamine hydrochloride for treatment of shock. The nurse should: 1. Administer pain medication concurrently. 2. Monitor blood pressure continuously. 3. Evaluate arterial blood gases at least every 2 hours. 4 Monitor for signs of infection.

112. 2. The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the I.V. infusion to maintain a systolic blood pressure of 90 mm Hg. Admin- istration of a pain medication concurrently with dopamine hydrochloride, which is a potent sym- pathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infec- tion is not related to the nursing action for the client receiving dopamine hydrochloride.

113. A male client who has been taking warfarin (Coumadin) has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglo- bin, 11 g/dL; and hematocrit, 33%. Which of the following physician orders should the nurse expect to implement initially? Select all that apply. 1.Administer I.V. dextrose 5% in 0.45% normal saline solution. 2. Schedule client for a sigmoidoscopy in the morning. 3. Give 1 unit fresh frozen plasma (FFP). 4. Administer vitamin K (AquaMEPHYTON) 2.5 mg P.O. 5. Begin giving polyethylene glycol-electrolyte solution (GoLYTELY) in preparation for sig- moidoscopy. 6. Administer Fleet enema

113. 1, 3, 4. Analysis of the client's laboratory results would indicate that an INR of 8 is increased beyond therapeutic ranges. The client is also expe-riencing severe acute rectal bleeding and has a hemoglobin level in the low range of normal and a hematocrit reflecting fluid volume loss. Getting the I.V. line started is crucial so that this client can receive FFP immediately. FFP contains concentrated clotting factors and provides an immediate reversal of the prolonged INR. Vitamin K 2.5 mg P.O. should be given next because it reverses the warfarin by returning the PT to normal values. However, the reversal process occurs over 1 to 2 hours. The other orders should be completed after these initial orders are in progress.

114. The nurse in the preoperative holding area keeps a client with gastric bleeding in a dimly lit envi- ronment with one family member present. What is the primary rationale for these nursing interventions? ■ 1. To stabilize fluid and electrolyte balance. ■ 2. To minimize oxygen consumption. ■ 3. To increase client and family comfort. ■ 4. To prevent infection.

114. 2. Nursing interventions to provide warmth and rest and minimize anxiety decrease the body's need for oxygen and nutrients. This is important for a client who has lost 500 mL or a unit of blood in a short period from a gastric hemorrhage. If the client has been stabilized, the fluid and electrolyte balance has already been established for the present. The comfort of the client and family is always impor- tant and is actually accomplished while the client's oxygen consumption is being minimized, which is a priority and the primary rationale. These nursing interventions are not specific to the prevention of infection.

115. When assessing a client for early septic shock, the nurse observes for which of the following? ■ 1. Cool, clammy skin. ■ 2. Warm, flushed skin. ■ 3. Decreased systolic blood pressure. ■ 4. Hemorrhage.

115. 2. Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confu- sion; decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

116. A client with toxic shock has been receiving ceftriaxone sodium (Rocephin), 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory findings does the nurse monitor? ■ 1. Serum creatinine. ■ 2. Spinal fluid analysis. ■ 3. Arterial blood gases. ■ 4. Serum osmolality.

116. 1. The nurse monitors the blood levels of antibiotics, white blood cells, serum creatinine, and blood urea nitrogen because of the decreased perfu- sion to the kidneys, which are responsible for filter- ing out the Rocephin. It is possible that the clear- ance of the antibiotic has been decreased enough to cause toxicity. Increased levels of these laboratory values should be reported to the physician imme- diately. A spinal fluid analysis is done to examine cerebral spinal fluid, but there is no indication of central nervous system involvement in this case. Arterial blood gases are used to determine actual blood gas levels and assess acid-base balance. Serum osmolality is used to monitor fluid and electrolyte balance.