Med-Surge Nursing Shock Prep U ch. 14

When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal?

Treat the oxygenation needs of the heart muscle As with all forms of shock, the underlying cause of cardiogenic shock must be corrected. It is necessary first to treat the oxygenation needs of the heart muscle to ensure its continued ability to pump blood to other organs.

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?

In the compensation stage, catecholamines are released. Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage.

En route to the ED, a client's systolic BP was 98 mm Hg and sinking. Which systolic BP supports the diagnosis of shock? Select all that apply.

1. 80 mm Hg 2. 75 mm Hg 3. 72 mm Hg For a normotensive adult, average systolic BP is 120 mm Hg. Therefore, a systolic BP of 90 to 100 mm Hg indicates impending shock, whereas 80 mm Hg or below indicates shock.

Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation? Select all that apply.

1. Acid-base imbalance 2. Decreased capillary permeability and fluid and electrolyte shifts 3. Increased blood urea nitrogen and serum creatinine In decompensation, the MAP would be less than 65 mm Hg, and the heart rate would be tachycardic or erratic with instances of asystole.

Which of the following clinical manifestations occur in cardiogenic shock?

Blood pressure falls When stroke volume and heart rate decrease or become erratic, blood pressure falls, and systemic tissue perfusion is compromised (urine output decreases, cold, clammy skin, mental status changes, anxiety, and delayed capillary refill).

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis?

Irreversible The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation?

Mean arterial pressure of 70 mm Hg The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?

Myocardial depression The body's inability to meet increased oxygen requirements produces ischemia, and biochemical mediators cause myocardial depression. This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin.

Which vasodilator medication is used in the treatment of shock?

Nitroglycerin Nitroglycerin is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Dopamine and dobutamine are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Norepinephrine is a vasoconstrictor used to increase blood pressure by vasoconstriction.

The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines?

Sodium and glucose levels In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines.

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order?

"Infuse I.V. fluids at 83 ml/hour." Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.

A patient is in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse?

"The healthcare team needs room to do procedures to help your family member, so it would be best if you stayed in the waiting area." As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided—throughout the patient's care—for the family to see, touch, and talk to the patient. However, the family should be encouraged to stay primarily in the waiting area, so as not to be in the way of health care workers.

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.

1. Vital signs 2. Skin color 3. Urine output 4. Peripheral pulses Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised.Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation.

A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply.

1. heart fails as effective pump 2. blood volume decreases 3. peripheral vascular dilation Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock develops as a consequence of one of three events: (1) blood volume decreases, (2) the heart fails as an effective pump, or (3) peripheral blood vessels massively dilate (Wedro, 2014).

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?

70% Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.

Colloids are used to expand intravascular volume in fluid replacement therapy. The nurse monitors the central venous pressure (CVP) reading and continues fluid replacement to achieve a reading of:

8 to 10 mm Hg. The goal in colloidal fluid replacement is to achieve a CVP of 8 to 12 mm Hg or higher (normal = 2 to 8 mm Hg).

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers

A continuous infusion of total parenteral nutrition Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.

A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock?

A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Shock may have different causes (e.g., hypovolemic, cardiogenic, septic) but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Option B could reflect dependant edema and sepsis. Option C reflects hypovolemia. Option D is reflective of anaphylactic or distributive shock.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which organ?

Lungs During MODS, the organ failure usually begins in the lungs and is followed by failure of the liver, gastrointestinal system, and kidneys.

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits

Adventitious breath sounds The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?

Aorta Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall.

A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as

Compensatory The client's mentation, vital signs, and skin condition are those of a client in the compensatory stage of shock. Data are insufficient to support shock as either cardiogenic or circulatory in origin.

A client is scheduled for computed tomography (CT) scanning of the abdomen and reports an allergy to iodine. The best action of the nurse is to

Ask the client "How does your allergy manifest itself?" The nurse must assess the client for reactions to contrast agents. This would include the type of reaction. The nurse then communicates this information to the staff involved in the care of the client.

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock?

Circulatory (distributive) Vasodilatation, a prominent characteristic of circulatory/distributive shock, increases the space in the vascular bed. Central blood flow is reduced because peripheral vascular or interstitial areas exceed their usual capacity. Vasodilation is not a major component of cardiogenic, hypovolemic, or obstructive shock.

The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by:

Cold, clammy skin and tachycardia. In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident.

A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse

Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) Pantoprazole tablets are not to be broken, crushed, or chewed. Lansoprazole is substituted for this medication. The nurse consults with the physician about substituting another proton pump inhibitor for pantoprazole. Enteral feedings are initiated at a slow rate to ensure adequate digestion. The nasogastric tube is measured from earlobe to xiphoid process and 6 inches are added to the length of the tube to be inserted. Placement of a PEG tube is not necessary at this time. The client is unstable. The tube is meant for long-term, not short-term, placement.

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

Decompensation The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis. Therefore, options A, B, and C are incorrect.

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is

Dextran Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

In which type of shock does the patient experience a mismatch of blood flow to the cells?

Distributive Distributive or vasogenic shock results from displacement of blood volume, creating a relative hypovolemia. Cardiogenic shock results from the failure of a heart as a pump. In hypovolemic shock, there is a decrease in the intravascular volume. In septic shock, overwhelming infection results in a relative hypovolemia.

The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock?

Distributive The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. This makes options A, C, and D incorrect.

A patient in shock would exhibit which one of the following clinical findings?

Metabolic acidosis The stage of shock exhibits a metabolic acidosis, a PaO2 of less than 80 mm Hg and a heart rate of over 150 bpm. In shock, anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid.

The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?

Increase in arterial oxygenation Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.

A client has the following vital signs: temperature 101.4 degrees F, blood pressure 88/54, pulse 128 beats/minute, and respirations 34 breaths/minute. Physician orders are shown in the accompanying chart. The nurse first intervenes by Chart: Physician orders: - D5LR at 150mL/hr - Vancomycin 1g IV every 12 hours - Acetaminophen (Tylenol) 650 mg by mouth q4h pm temperature greater than 101 degrees F - Blood cultures 2 X 15 minutes apart STAT

Increasing DRLR to the prescribed rate All these options are appropriate for the client who is in septic shock, but the nurse would first administer the IV fluids to restore vascular volume. Blood cultures would be obtained prior to administration of any antibiotics. Acetaminophen is given to provide comfort to the client.

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?

Lactated Ringer's Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first

Lays the client flat with the feet elevated The client may have fainted, which is a sign of transient neurogenic shock. To minimize pooling of blood in the legs and to restore blood flow to the brain, the nurse lays the client flat and elevates his or her feet. Another cause may be hypoglycemia. If the above action does not resolve the client's problem, the nurse should assess the client's blood glucose level. Raising the head of the bed would be done if the client had received spinal or epidural anesthesia. A bolus of IV fluids would be given if the client were dehydrated.

Which positioning strategy should be used for the client diagnosed with hypovolemic shock?

Modified Trendelenburg A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position?

Modified Trendelenburg The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.

Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock?

Neurogenic The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart?

Nitroprusside A disadvantage of nitroprusside (Nipride) is that it causes hypotension. Dopamine (Intropin) improves contractility, increases stroke volume, and increases cardiac output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

Oxygen at 2 L/min by nasal cannula In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as

Progressive The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin.

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock?

Progressive In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg?

Progressive In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.

The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in?

Progressive In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline.

The nurse anticipates that a client who is immunosuppressed is at the greatest risk for developing which type of shock?

Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. Neurogenic shock is associated with spinal cord injury and anesthesia. Cardiogenic shock is associated with disease of the heart. Anaphylactic shock is associated with hypersensitivity reactions.

You are assessing a 6-year-old girl in the Emergency Department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?

She is having an allergic reaction and going into anaphylactic shock. Anaphylactic shock is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive. Common allergic substances include bee venom, latex, fish, nuts, and penicillin. The body's immune response to the allergic substance causes mast cells in the connective tissues, bronchi, and gastrointestinal tract to release histamine and other chemicals. The results are vasodilatation, increased capillary permeability accompanied by swelling of the airway and subcutaneous tissues, hypotension, and hives or an itchy rash. Cardiogenic shock, neurogenic shock, and obstructive shock would not begin with vasodilation, swelling of the airway and hives. Therefore, options A, C ,and D are incorrect.

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock?

The client with testicular cancer who is receiving intravenous chemotherapy Risk factors for septic shock include immunosuppression, such as with the client who has testicular cancer and is receiving chemotherapy. Other risk factors include age younger than 1 year or greater than 65 years, malnourishment, chronic illness, and invasive procedures. None of the other clients meets these risk factors or has a greater risk for invasive procedures than the client with testicular cancer.

The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of a client who has

an overwhelming bacterial infection. Unlike other forms of shock, clients with septic shock have an elevated leukocyte count and initially manifest fever accompanied by warm, flushed skin and a rapid, bounding pulse. Therefore, the client with an overwhelming bacterial infection is most likely to exhibit these symptoms. Extreme loss of blood causes hypovolemic shock; an overdose of opioids causes neurogenic shock; and a severe allergic reaction causes anaphylactic shock.

A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing?

decompensation stage Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. This client's symptoms, particularly the dropping BP, indicate the decompensation stage. During the compensation stage of shock, physiologic mechanisms attempt to stabilize the spiraling consequences. During the irreversible stage, the client no longer responds to medical interventions, and multiple systems begin to fail. Cardiogenic shock is a type of shock.

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

5% albumin Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared to crystalloid solutions. Hetastarch and dextran solutions are not indicated for fluid administration because these agents interfere with platelet aggregation. Blood products are not indicated in this situation.

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:

A myocardial infarction. Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client?

Control the shivering. Hyperthermia may develop related to altered temperature regulation secondary to sepsis. Because the act of shivering increases body heat through the contraction of skeletal and pilomotor muscles in the skin, it is important to get the shivering under control. Use of a warming blanket would not be an appropriate intervention because this client is septic and hyperthermic. Conduction and radiation transfer heat, which would increase the client's body temperature. Keeping the client dry and covered would not help this situation because measures that prevent evaporation and heat loss from radiation interfere with the loss of body heat. Supine positioning with elevated legs is appropriate for clients with ineffective peripheral tissue perfusion.

Which of the following is the most common side effect of recombinant human activated protein C (rhAPC)?

Bleeding Bleeding is the most common serious side effect. The nurse monitors closely the response to this treatment, particularly in patients with known bleeding risks, such as chronic liver disease. Bone marrow suppression, peripheral edema, and muscle cramps are not a common side effect of this medication.

Which of the following is a clinical characteristic of neurogenic shock?

Bradycardia The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

Older adults with impaired cardiac function are more likely to develop which type of shock?

Cardiogenic shock Older adults, particularly those with decreased cardiac function, are prone to cardiogenic shock. Typically, underlying causes of septic shock is circulatory in nature and caused by infection, neurogenic shock occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation, and anaphylactic shock is caused by a severe allergic reaction.

What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client?

Decreased blood pressure. A potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently according to the manufacturer's recommendation and institutional policy.

How should vasoactive medications be administered?

Using a central venous line Vasoactive medications should be administered through a central venous line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV push.

A client presents to the emergency department with her spouse. The client appears to be in respiratory distress. The spouse states, "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which agent first?

Epinephrine intramuscularly All of the interventions are indicated in the treatment of anaphylactic shock. However, IM epinephrine is administered first because of its vasoconstrictive action. IV Diphenhydramine is administered to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications such as albuterol may be given to reverse histamine-induced bronchospasm. Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability.

A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock?

HR, 48 bpm; BP, 90/60 mm Hg The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. The other signs and symptoms are associated with hypovolemic shock.

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?

Levophed The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in the

lungs. During MODS, the organ failure usually begins in the lungs and is followed by failure of the liver, gastrointestinal system, and kidneys.

Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as

sodium nitroprusside. Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.

The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?

"A pulmonary artery pressure provides information about pressure on the left side of the heart." The most pertinent information to share with a new nurse is the information that the pulmonary artery pressure provides essential information about the effectiveness of left ventricle. The left ventricle is most pertinent to circulation. The other information is correct but not as pertinent.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply.

1. Burns 2. Dehydration The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply.

1. Famotidine (Pepcid) 2. Ranitidine 3. Lansoprazole Antacids, H2 blockers (Pepcid, Zantac), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Desmopressin (DDVAP) is used in the treatment of diabetes insipidus. Furosemide (Lasix) is a loop diuretic and does not prevent ulcer formation.

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply.

1. Hypovolemic shock; blood loss 2. Cardiogenic shock; myocardial infarction 3. Anaphylactic shock; nuts 4. Septic shock; infection Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interfere in blood flow through the heart . Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.

The nurse is caring for a client with a central venous line in place for the treatment of shock. Which nursing interventions are essential for the nurse to complete in order to reduce the risk of infection? Select all that apply.

1. Maintain sterile technique when changing the central venous line dressing. 2. Always perform hand hygiene before manipulating or accessing the line ports. 3. Apply clean gloves before accessing the line port. The following nursing interventions are essential to reduce the risk of infection: maintain sterile technique when changing the central venous line dressing; always perform hand hygiene before manipulating or accessing the line ports; apply clean gloves before accessing the line port; and perform a 15- to 30-second "hub scrub" using chlorhexidine or alcohol and friction in a twisting motion on the access hub. The latter reduces biofilm on the hub that may contain pathogens.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply.

1. Increased paCO² levels 2. Reports of chest pain 3. Loss in consciousness 4. Ecchymoses and petechiae The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activites of the liver are impaired, and liver enzymes will increase.

Which of the following vasoactive medications may be used in the treatment of cardiogenic shock? Select all that apply.

1. Norepinephrine (Levophed) 2. Milrinone (Primacor) 3. Amrinone (Inocor) Vasoactive agents that may be used in managing cardiogenic shock include Levophed, Adrenalin, Primacor, Inocor, Pitressin, and Neo-Synephrine. Each of these medications stimulates different receptors of the sympathetic nervous system.

A client with diabetes is in the emergency department because of vomiting, diarrhea, and weight loss of 8 pounds over 2 days. Vital signs taken by the triage nurse indicate the client is in hypovolemic shock. Place the nurse's steps in the correct order.

1. Place the client in the modified Trendelenburg position. 2. Initiate an intravenous (IV) site and prescribed IV fluids. 3. Assess the capillary blood glucose level. 4. Collect a stool specimen for culture. The nurse provides care based on Maslow's hierarchy of needs. The client in shock should be properly positioned first. Then, an IV insertion site and fluids need to be started to correct the hypovolemic shock. Because the client is diabetic, the blood glucose level needs to be assessed and treated. Finally, collection of a stool specimen will be important to assess the cause of the gastrointestinal distress.

A client is unstable and receiving dopamine to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all that apply.

1. Use an intravenous controller or pump. 2. Verify dosage and pump settings with another RN. 3. Measure urine output every hour. It is recommended to administer vasoactive drugs, such as dopamine (Inotropin), through a central line. The nurse assesses vital signs every 15 minutes until stable. The nurse uses an intravenous controller or pump to ensure accurate infusion and verifies the dosage and pump settings with another RN. The nurse also measures urine output every hour.

The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour?

2.7 mL/hr The nurse should administer 2.7 mL/hr: 1 mcg/90 kg/60 minutes/2,000 (concentration)

The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate?

3:1 IV fluids are prescribed to restore intravascular volume. The total volume, type of solution(s), and rate of administration vary according to the etiology of shock. Usually, a ratio of 3:1 is followed; that is, 3 L of fluid is administered for every 1 L of fluid lost.

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement?

Administer norepinephrine as prescribed. Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:

Constrict blood vessels in the cardiorespiratory system. Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

Clinical characteristics of neurogenic shock are noted by which type of stimulation?

Parasympathetic The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The client experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation.

The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body?

Production of antidiuretic hormone and corticosteroid hormones Thus, antidiuretic hormone (ADH) and corticosteroid hormones play an active role in controlling sodium and water balance. Both ADH and corticosteroid hormones, then, promote fluid re absorption and retention. The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. The release of catecholamines stimulates secretion of epinephrine and norepinephrine.

The nurse is caring for a client in the compensation stage of shock. The nurse knows that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do?

Restores blood pressure The renin-angiotensin-aldosterone systemis a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone.

A client receives alteplase (t-PA). It is most important for the nurse to intervene when

The client's Glasgow Coma Score changes from 15 to 13. Alteplase is a thrombolytic. It is important for the nurse to assess for bleeding. A change in the Glasgow Coma Score may indicate cerebral hemorrhage. Bleeding at venous puncture sites and possibly in the joints is less critical. A normal sinus rhythm with few premature ventricular contractions may be an improvement in the client's cardiac status and indicates lysis of thrombi in the coronary arteries.

The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately?

The client's heart rate is greater than 90 beats per minute. A heart rate greater than 90 beats per minute or a respiratory rate greater than 20 breaths per minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?

The patient has developed a stress ulcer that is bleeding. GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus.

The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.)

1. Activation of the inflammatory response 2. Hypoperfusion of tissues 3. Must produce energy through anaerobic metabolism Regardless of the initial cause of shock, certain physiologic responses are common to all types of shock. These physiologic responses include hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response. The body responds to shock states by activating the sympathetic nervous system and mounting a hypermetabolic and inflammatory response. Failure of compensatory mechanisms to effectively restore physiologic balance is the final pathway of all shock states and results in end-organ dysfunction and death. In shock, the cells lack an adequate blood supply and are deprived of oxygen and nutrients; therefore, they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients and an acidotic intracellular environment. Because of these changes, normal cell function ceases (Fig. 14-1). The cell swells and the cell membrane becomes more permeable, allowing electrolytes and fluids to seep out of and into the cell.

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply.

1. Assess the client who is at risk for shock. 2. Administer intravenous fluids. 3. Monitor for changes in vital signs. Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply.

1. The client who is in the first 15 minutes of receiving 1 unit of PRBCs 2. The 55 year-old client with spina bifida 3. The client who reports an allergy to peanuts that causes throat swelling Risk factors for anaphylactic shock include transfusion reaction, latex allergy, and severe allergy to foods or medications. The client in the first 15 minutes of receiving blood is at risk for an anaphylactic reaction. This is why the nurse should remain in the room for the first 15 minutes of infusion. The client with spina bifida is at risk for a latex allergy, which, in turn, increases the risk for an anaphylactic reaction if latex gloves are used. The client with a peanut allergy is at risk for an anaphylactic reaction if food is prepared or accidentally contaminated with a nut-based oil. The other clients are not at an increased risk for anaphylactic shock.

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?

24 The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse.

The nurse is calculating a patient's mean arterial pressure (MAP). What is the patient's MAP, if the blood pressure is 110/70 mm Hg?

83 Tissue perfusion and organ perfusion depend on mean arterial pressure (MAP), or the average pressure at which blood moves through the vasculature. MAP must exceed 65 mm Hg for cells to receive the oxygen and nutrients needed to metabolize energy in amounts sufficient to sustain life (Dellinger et al., 2013; Tuggle, 2010). True MAP can be calculated only by complex methods. An estimate of MAP may be calculated by using the following equation: MAP = DP + 1/3 (SP - DP). So, in this case, MAP = 70 + 1/3 (110-70) = 70 + 40/3 = 70 + 13.33 = 83.33, which rounds to 83.

The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation?

Pedal pulse stronger The ventricular assist device (VAD) is a medical mechanical device used to improve cardiac output and redistribute blood. The best evidence to confirm successful implementation is by identifying a strong pedal pulse in a lower extremity. Respiratory rate decreases as a client rests. Heart rate decreases when the tissues obtain the needed oxygen. The temperature within normal limits does not confirm successful implementation.

A client experienced hemorrhage following a gunshot to the chest and received massive amounts of fluids. The client is now stable. The nurse assesses abdominal pressure as 12 mm Hg. The most immediate nursing intervention is to

Raise the head of the client's bed. Normal abdominal pressures are 0 to 5 mm Hg. The client may be experiencing abdominal compartment syndrome, an increase in the pressure of the abdominal cavity. This is from fluid leaking into the intra-abdominal cavity and results in elevating the client's diaphragm. Raising the head of the bed will promote easier breathing. The other options may be done by the nurse, but ensuring adequate oxygenation is the priority.

A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse

Raises the foot of the client's bed The description of the client is that of a person experiencing shock. In addition to administering fluids to a client in shock, the nurse positions the client with the legs elevated, which promotes venous blood return. Elevating the head of the bed will cause the client's blood pressure to drop even more. The Trendelenburg position will make breathing difficult and does not increase blood pressure or cardiac output. Placing the client in a side-lying position does not increase venous blood return.