MEDSURG TEST #3: CH 66 - Shock, Sepsis, and MODS

Which of these conditions is indicative distributive shock? (Select All) A. Big MI B. 16 y/0 who dives into a pool and becomes a quad C. An 86 y/o who is admitted for urosepsis D. A GI bleed that you're getting from ER

B. 16 y/0 who dives into a pool and becomes a quad C. An 86 y/o who is admitted for urosepsis

The nurse is caring for a patient being treated with an intraaortic balloon pump. Which intervention is most important to include in the patient's plan of care? A. Turning side to side every 2 hours B. Assessing peripheral pulses C. Padding bony prominences D. Applying splint to affected limb

B. Assessing peripheral pulses

Appropriate treatment modalities for the management of cardiogenic shock include (SATA). a. dobutamine to increase myocardial contractility b. vasopressors to increase SVR c. circulatory assist devices such as an intraaortic balloon pump d. corticosteroids to stabilize the cell wall in the infarcted myocardium e. Trendelenburg position to facilitate venous return and increase preload

a. dobutamine to increase myocardial contractility c. circulatory assist devices such as an intraaortic balloon pump

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? a. Give PRN furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Administer hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

a. Give PRN furosemide (Lasix) 40 mg IV. Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

a. Give normal saline IV at 500 mL/hr.

A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg. d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

a. Infuse normal saline at 250 mL/hr. The patient's elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the patient.

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Heart rate 112 beats/minute c. Decreased bowel sounds d. Pale, cool, and dry extremities

a. New onset of confusion The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow oxygen (100%) by non-rebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

a. Prepare to administer atropine IV. b. Obtain baseline body temperature. d. Provide high-flow oxygen (100%) by non-rebreather mask. e. Prepare for emergent intubation and mechanical ventilation. All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient's central venous pressure is 3 mm Hg. b. The patient is in sinus tachycardia at 120 beats/min. c. The patient is receiving low dose dopamine (Intropin). d. The patient has had no urine output since being admitted.

a. The patient's central venous pressure is 3 mm Hg. Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

a. The patient's serum creatinine level is elevated.

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. obtain a 12-lead electrocardiogram (ECG). c. obtain the blood pressure. d. check the level of consciousness.

a. administer oxygen.

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% human albumin b. Furosemide (Lasix) IV c. Epinephrine (Adrenalin) drip d. Hydrocortisone (Solu-Cortef)

b. Furosemide (Lasix) IV The PAWP indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Start a normal saline infusion. b. Give epinephrine (Adrenalin). c. Start continuous ECG monitoring. d. Give diphenhydramine (Benadryl).

b. Give epinephrine (Adrenalin).

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

b. Monitor breath sounds frequently. Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics Antibiotics should be administered within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS) and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute

b. Skin cool and clammy

Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

b. Urine output is 60 mL over the last hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. nitroglycerine (Tridil). b. norepinephrine (Levophed). c. sodium nitroprusside (Nipride). d. methylprednisolone (Solu-Medrol).

b. norepinephrine (Levophed). When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside is an arterial vasodilator and would further decrease SVR.

A 64-yr-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure of 78/58 mm Hg, pulse of 124 beats/min, respirations of 28 breaths/min, and temperature of 97.2°F (36.2°C). Which physician order should the nurse complete first? a. obtain a 12-lead ECG and arterial blood gases b. rapidly administer 1000 mL normal saline solution IV c. administer norepinephrine by continuous IV infusion d. carefully insert a NG tube and an indwelling bladder catheter

b. rapidly administer 1000 mL normal saline solution IV

A 78-year-old man has confusion and temperature of 104F. He is a diabetic with purulent drainage from his right heel. After an infusion of 3L of normal saline solution, his assessment findings are BP 84/40; heart rate 110; respiratory rate 42 and shallow; CO 8L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of a. sepsis b. septic shock c. multiple organ dysfunction syndrome d. systemic inflammatory response syndrome

b. septic shock

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? a. bradycardia b. ventricular dysrhythmias c. rising diastolic blood pressure d. falling central venous pressure

b. ventricular dysrhythmias

A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles. b. Cool, clammy extremities. c. Apical heart rate 45 beats/min. d. Temperature 101.2° F (38.4° C).

c. Apical heart rate 45 beats/min. Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? a. Increase the rate for the dopamine (Intropin) infusion. b. Decrease the rate for the nitroglycerin (Tridil) infusion. c. Increase the rate for the sodium nitroprusside (Nipride) infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

c. Increase the rate for the sodium nitroprusside (Nipride) infusion. Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Initiate continuous electrocardiogram (ECG) monitoring. c. Provide oxygen at 100% per non-rebreather mask. d. Draw blood to type and crossmatch for transfusions.

c. Provide oxygen at 100% per non-rebreather mask. The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize oxygen delivery have been implemented.

Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient's heart rate is 110 beats/minute. c. The patient is complaining of chest pain. d. The patient's peripheral pulses are weak.

c. The patient is complaining of chest pain.

The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/minute. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the last hour.

c. The patient's IV infusion site is cool and pale. The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action

A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure 92/40 mm Hg

c. Warm, pink, and dry skin

The nurse is caring for a 29-yr-old man who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The attending physician states the patient has developed sepsis, and the family members have many questions. Which information should the nurse include when explaining the early stage of sepsis? a. antibiotics are not useful when an infection has progressed to sepsis b. weaning the patient away from the ventilator is the top priority in sepsis c. large amounts of IV fluids are required in sepsis to fill dilated blood vessels d. the patient has recovered from sepsis if he has warm skin and ruddy cheeks

c. large amounts of IV fluids are required in sepsis to fill dilated blood vessels

The nurse is caring for a 72-yr-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be most concerning? a. restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds b. mean arterial pressure 54, increased jaundice, and cold, clammy skin c. paO2 of 38, serum lactate level of 46.5, and puncture site bleeding d. agitation, RR of 32, and serum creatinine of 2.6

c. paO2 of 38, serum lactate level of 46.5, and puncture site bleeding

The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. hypothermia blanket. b. lactated Ringer's solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.

c. two 14-gauge IV catheters. A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Palpate for abdominal pain. c. Ask the patient about nausea. d. Check stools for occult blood.

d. Check stools for occult blood.

The nurse admits a 35-year-old patient to the emergency department following a 3-day history of nausea and vomiting. Vital signs assessed by the nurse include a BP of 70/50 mm Hg, HR 145 beats/min, RR 36 breaths/min, and SpO2 of 92% on room air. The nurse recognizes which classification of shock? a. Cardiogenic b. Anaphylactic c. Obstructive d. Hypovolemic

d. Hypovolemic

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock

d. Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

d. Oxygen saturation Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

What laboratory finding is consistent with a medical diagnosis of cardiogenic shock? a. decreased liver enzymes b. increased white blood cells c. decreased red blood cells, hemoglobin, and hematocrit d. increased BUN and Cr

d. increased BUN and Cr

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a. acute pain b. impaired skin integrity c. decreased CO d. ineffective tissue perfusion

d. ineffective tissue perfusion

the most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations b. breath sounds, blood pressure, and body temperature c. pulse pressure, level of consciousness, and pupillary response d. level of consciousness, urine output, and skin color and temperature

d. level of consciousness, urine output, and skin color and temperature

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing a. a relative hypervolemia b. an absolute hypovolemia c. neurogenic shock from low blood flow d. neurogenic shock from massive vasodilation

d. neurogenic shock from massive vasodilation

After coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care? a. cardiac index of 5 L/min/m2 b. central venous pressure of 8 c. mean arterial pressure of 86 d. pulmonary artery pressure of 28/14

d. pulmonary artery pressure of 28/14