MedSurg3: Exam 3 Shock

The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient? A. Platelets B. Albumin C. Fresh Frozen Plasma D. Packed Red Blood Cells

C. Fresh Frozen Plasma The answer is C. A patient who needs clotting factors would benefit from fresh frozen plasma (FFP).

You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority? A. Keeping the head of the bed greater than 45 degrees at all times. B. Repositioning the patient every thirty minutes. C. Keeping the patient's spine immobilized. D. Avoiding log-rolling the patient during transport.

C. Keeping the patient's spine immobilized. The answer is C. It is very important when a patient has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient's spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.

Which of the clients under the nurse's care is at an increased risk for sepsis or septic shock?

What causes an increased risk for sepis/septic shock?

A client begins experiencing wheezing, anxiety, swelling, and hives after eating shellfish and is brought to the emergency department. Which immediate action would the nurse implement? 1. Administer epinephrine. 2. Maintain a patent airway. 3. Administer a corticosteroid. 4. Apply a MedicAlert bracelet.

2. Maintain a patent airway. Test-Taking Strategy:Focus on the strategic word, immediate, which tells you that you need to prioritize your nursing actions. Use the ABCs—airway, breathing, and circulation—to answer the question. The airway is always the priority.

The nurse is caring for a client in septic shock with hyperlactatemia. The nurse notes the first serum lactate level was drawn at 1200. When would the nurse expect the next lactate level to be drawn? 1. 1400 2. 1600 3. 1800 4. 2000

3. 1800 Rationale:While caring for the client with sepsis, if the initial serum lactate level is elevated, it needs to be redrawn in 6 hours. Therefore, if the first value was drawn at 1200, the next level would be drawn at 1800. Therefore, option 3 is correct.

A patient has lost 750 mL of blood volume. The MD orders Normal Saline infusion. Using the 3:1 rule, how much crystalloid solution should be prescribed by the doctor? A. 2,250 mL of Normal Saline B. 250 mL of Normal Saline C. 375 mL of Normal Saline C. 1,225 mL of Normal Saline

A. 2,250 mL of Normal Saline The answer is A. For crystalloid solutions (this includes normal saline and lactated ringer's), a 3:1 rule is used. This rule states for every 1 mL of approximate blood loss 3 mL of crystalloid solution is given. Therefore, if the patient loses 750 mL of blood, the patient would receive 2,250 mL of saline. 750 x 3 = 2,250

What is the MOST important step a nurse can take to prevent anaphylactic shock in a patient? A. Assessing, documenting, and avoiding all the patient allergies B. Administering Epinephrine C. Administering Corticosteroids D. Establishing IV access The answer is A. This is the MOST important and easiest step a nurse can take in preventing anaphylactic shock in a patient.

A. Assessing, documenting, and avoiding all the patient allergies The answer is A. This is the MOST important and easiest step a nurse can take in preventing anaphylactic shock in a patient.

You're providing an in-service to new nurse graduates on the fluid treatment for hypovolemic shock. You ask the participants to list the types of crystalloid solutions used in hypovolemic shock. Which responses are INCORRECT? Select all that apply: A. Albumin B. Lactated Ringer's C. Normal Saline D. Hetastarch

A. Albumin D. Hetastarch The answers are A and D. Albumin and Hetastarch are COLLOID solutions...not crystalloid. Lactated Ringer's and Normal Saline are considered crystalloid solutions and are used in the treatment of hypovolemic shock.

Your patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in your patient, would indicate the medication is working? A. Decreased CVP (central venous pressure) B. Mean arterial pressure (MAP) 90 mmHg C. Serum lactate 6 mmol/L D. Blood pH 7.20

B. Mean arterial pressure (MAP) 90 mmHg The answer is B. A MAP of 85-90 mmHg will help maintain tissue perfusion and indicates the vasopressor is working to maintain tissue perfusion. It does this by causing vasoconstriction. Options A, C, and D would indicate tissue perfusion is decreased.

A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action? A. Patient heart rate is 115 bpm B. Patient experiences dyspnea and crackles in lung fields C. Patient is anxious D. Patient's urinary output is 35 mL/hr

B. Patient experiences dyspnea and crackles in lung fields The answer is B. When crystalloid fluids are given there is a risk for fluid volume overload even though the patient is hypovolemic, especially with rapid infusions. Therefore, the nurse should monitor the patient for this. If a patient develops difficulty breathing (dyspnea) and has crackles in the lung fields (this represents edema in the lungs), fluid is backing up in the lungs. This requires immediate nursing action. Option A and C are expected finding in hypovolemic shock, and option D is a normal finding...urinary output should be >30 mL/hr.

A patient is in anaphylactic shock. The patient has a severe allergy to peanuts and mistakenly consumed an eggroll containing peanut ingredients during his lunch break. The patient is given Epinephrine intramuscularly. As the nurse, you know this medication will have what effect on the body? A. It will prevent a recurrent attack. B. It will cause vasoconstriction and decrease the blood pressure. C. It will help dilate the airways. D. It will help block the effects of histamine in the body.

C. It will help dilate the airways. Epinephrine acts as a vasopressor and will actually dilate the airway. Epinephrine performs vasoconstriction which will INCREASE the blood pressure. It does not prevent a recurrent attack (corticosteroids may help with this), and it does not block the effects of histamine (antihistamine helps with this).

Which statement is true about colloid solutions? Select all that apply: A. These solutions are made up of large molecules that cannot diffuse through the capillary wall, so more fluid stays in the intravascular space longer when compared with the action of a crystalloid solution. B. These solutions can diffuse through the capillary wall so less fluid stays in the intravascular system when compared to the action of a crystalloid solution. C. The nurse should monitor for an anaphylactic reaction when these products are administered. D. These fluids are considered hypertonic solutions.

C. The nurse should monitor for an anaphylactic reaction when these products are administered. The answers are A and C. These are true statements about colloid solutions. Options B and D are incorrect.

A patient in septic shock is experiencing hyperglycemia. The patient is started on an insulin drip. A blood glucose goal for this patient would be: A. <110 mg/dL B. <80 mg/dL C. >200 mg/dL D. <180 mg/dL

D. <180 mg/dL The answer is D. If a patient is experiencing hyperglycemia an insulin drip may be ordered to control glucose levels. Hyperglycemia affects the immune system and healing. A blood glucose goal in this patient is <180 mg/dL.

The nurse is told by a primary health care provider that a client in hypovolemic shock will require plasma expansion. The nurse would prepare which supplies for transfusion? 1. Bag of platelets with filtered tubing 2. Bottle of albumin with vented tubing 3. Cryoprecipitate bag with vented tubing 4. Infusion pump and bag of packed red blood cells

2. Bottle of albumin with vented tubing Rationale: Albumin may be used as a plasma expander. Albumin is supplied in a bottle, and vented tubing is required for transfusion. Platelets are used when the client's platelet count is low. Cryoprecipitate is useful in treating bleeding from hemophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. Cryoprecipitate is usually supplied in bags, so vented tubing is not required. Packed red blood cells replace erythrocytes and are not a plasma expander.

Which Pokeman is Poikilothermia?

An environmental temperature one with temperature dysregulation.

You're precepting a new nurse. You ask the new nurse to list the purpose of why a patient with cardiogenic shock may benefit from an intra-aortic balloon pump. What responses below indicate the new nurse understands the purpose of an intra-aortic balloon pump? Select all that apply: A. "This device increases the cardiac afterload, which will increase cardiac output." B. "This device will help increase blood flow to the coronary arteries." C. "The balloon pump will help remove extra fluid from the heart and lungs." D. "The balloon pump will help increase cardiac output."

B. "This device will help increase blood flow to the coronary arteries." D. "The balloon pump will help increase cardiac output." The answers are B and D. An intra-aortic balloon pump increases coronary artery blood flow and cardiac output.

As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose __________ of their blood volume. A. <30% B. >25% C. >15% D. >10%

C. >15% The answer is C. As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose 15% or more of their blood volume.

A patient is having an anaphylactic reaction to an IV medication. What is the FIRST action the nurse should take? A. Administer Epinephrine B. Call a Rapid Response C. Stop the medication D. Administer a breathing treatment

C. Stop the medication The answer is C. The FIRST step the nurse should take is to immediately remove the allergen. This would be stopping the medication, and then call a rapid response. The nurse should maintain the airway and start CPR (if needed) until help arrives.

Types of shock

Cardiogenic - Pump failure Hypovolemic - Low volume Anaphylactic - Severe allergic reaction Septic (distributive) [I] - Sepsis + Organ dysfunction + Hypotension despite vasodilation efforts. Neurogenic - Injury to T5 or higher causing widespread vasodilation Obstructive - Obstruction somewhere causing decreased CO CHAIN (O)

Does HR increase in neurogenic shock?

No - you fool.

The three main types of distributive shock are

septic shock, anaphylactic shock, and neurogenic shock.

Distributive shock, also known as vasodilatory shock, refers to

systemic vasodilation and decreased blood flow to vital organs such as the brain, heart, and kidneys. It can also cause fluid to leak from the capillaries into the surrounding tissues as a result.

.The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1. "Pulse rate will increase." 2 "Blood pressure will decrease." 3 "Edema will be present in the legs." 4 "Crackles in the lungs will be present."

1. "Pulse rate will increase." Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid volume.

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed? 1. 5% dextrose in lactated Ringer's 2. 0.33% sodium chloride (⅓ normal saline) 3. 0.225% sodium chloride (¼ normal saline) 4. 0.45% sodium chloride (½ normal saline)

1. 5% dextrose in lactated Ringer's Rationale:The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% dextrose in lactated Ringer's solution (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, would move into the cells via osmosis.

A client who had a myocardial infarction is at risk for cardiogenic shock. The nurse plans care knowing that the primary cause of cardiogenic shock results from which process? 1. A pump failure and reduction in cardiac output 2. A physical obstruction that decreases filling or outflow of blood 3. Dilated vasculature decreasing the movement of blood to the body 4. Loss of vasoconstrictor tone, leading to pooling of blood in vessels

1. A pump failure and reduction in cardiac output Rationale:Cardiogenic shock is caused by the heart itself not being able to pump effectively, resulting in decreased cardiac output. Cardiac output reflects blood reaching the tissues and vasculature. The remaining options do not describe the pathophysiology associated with cardiogenic shock.

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse plans for which intervention as the priority for this client? 1. Administration of dopamine 2. Administration of whole blood 3. Administration of intravenous fluids 4. Administration of packed red blood cells

1. Administration of dopamine Rationale: The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.

The nurse is caring for a client with systemic inflammatory response syndrome (SIRS) related to bacterial pneumonia. Which interventions would be most appropriate for this client? Select all that apply. 1. Electrocardiogram (ECG) monitoring 2. Fluid replacement 3. Frequent ambulation 4. Antibiotic administration 5. Venous thromboembolism prophylaxis

1. Electrocardiogram (ECG) monitoring 2. Fluid replacement 3. Frequent ambulation 5. Venous thromboembolism prophylaxis Rationale: Because SIRS is a systemic inflammatory response, several body systems may be involved that are unrelated to the original infection. It is important for the interventions to center on monitoring, restoring tissue perfusion, fluid volume, and correcting the underlying cause of infection. Frequent ambulation is an inappropriate intervention because of the systemic inflammatory response and the need for rest to assist in healing.

The nurse is caring for a postoperative client weighing 68 kilograms (kg) who began to show signs of altered mental status, decreased mean arterial pressure (MAP), hypotension, fever, and tachycardia. The nurse suspects sepsis and notifies the primary health care provider (PHCP). The nurse would anticipate which of the following interventions? Select all that apply. 1. Obtain blood cultures 2. Draw serum lactate levels 3. Administer broad-spectrum antibiotics 4. Administer intravenous (IV) normal serum human albumin 5. Administer 2 liters (L) of IV 0.9% normal saline solution over 1 hour

1. Obtain blood cultures 2. Draw serum lactate levels 3. Administer broad-spectrum antibiotics 5. Administer 2 liters (L) of IV 0.9% normal saline solution over 1 hour Rationale:The initial interventions for sepsis focus on correcting the underlying cause and preventing complications. Lactic acid levels rise in response to the body switching to anaerobic metabolism due to inadequate tissue perfusion. Blood cultures should be drawn to identify the causative infectious organism. Broad-spectrum antibiotics need to be administered after blood cultures are drawn. To treat the hypotension and inadequate perfusion, the client will require fluid resuscitation, and this is done by administering 30 mL/kg of a crystalloid solution. Human albumin would not be the appropriate initial treatment of septic shock; however, it is used in the treatment of hypovolemic shock. Therefore, options 1, 2, 3, and 5 are correct.

The nurse is caring for a client with no significant medical history who is receiving intravenous antibiotics for cellulitis of the right lower extremity. The nurse is reviewing the client's laboratory results and would determine that which of the following results are indicative of developing sepsis? Select all that apply. 1. Plasma glucose of 162 mg/dL (9 mmol/L) 2. Platelet count of 90,000 mm3 (90 × 109/L) 3. Venous lactic acid level of 7 mg/dL (0.84 mmol/L) 4. International normalized ratio (INR) of 1.2 5. White blood cell (WBC) count of 3,000 mm3 (3 × 109/L)

1. Plasma glucose of 162 mg/dL (9 mmol/L) 2. Platelet count of 90,000 mm3 (90 × 109/L) 5. White blood cell (WBC) count of 3,000 mm3 (3 × 109/L) Rationale:Sepsis is defined as a life-threatening organ dysfunction from a disrupted systemic host response to infection. Pathogens in the bloodstream trigger extensive inflammation, initiating systemic inflammatory response syndrome (SIRS), in which inflammation causes massive hormonal, tissue, and vascular changes that impair gas exchange and tissue perfusion via the release of pro-inflammatory cytokines. The release of the pro-inflammatory cytokines results in systemic vasodilation and decreased cardiac output. The body's compensatory mechanisms include decreased urine output and increased respiratory rate. Some clients may have a fever while others will have a lower-than-normal body temperature. SIRS also induces inappropriate clotting mechanisms in which microthrombi form in capillaries, further complicating organ hypoxia and dysfunction. Monitoring of laboratory values is critical in the care of a client at risk for sepsis or septic shock. Hyperglycemia with plasma glucose greater than 140 mg/dL (7.7 mmol/L) in a client with no history of diabetes mellitus is indicative of developing sepsis. Therefore, option 1 is correct. Thrombocytopenia with platelet count less than 100,000 mm3 (100 × 109/L) supports the possibility of developing sepsis. Therefore, option 2 is correct. WBC count may be elevated or depressed, with values greater than 12,000 mm3 (12 × 109/L) or less than 4,000 mm3 (4 × 109/L). Therefore, option 5 is supportive of developing sepsis. Lactic acid level is elevated in sepsis, and option 3 indicates a normal lactic acid level. Therefore, option 3 is not supportive of developing sepsis. An INR level of greater than 1.5 is indicative of sepsis. Therefore, a value of 1.2 does not meet the criteria and is incorrect.

Which finding indicates that tissue perfusion has been improved in a client with septic shock? 1. The client's capillary refill is less than 3 seconds. 2. The client's blood glucose has decreased to 120 mg/dL. 3. The client tolerated a rapid infusion of isotonic intravenous fluids. 4. The client's pulse oximetry is maintained at 94% on 4 liters per minute of oxygen via nasal cannula.

1. The client's capillary refill is less than 3 seconds. Rationale:The primary goal of treatment and management of shock is to improve tissue perfusion. Ongoing assessments to perform to note improvement in perfusion include capillary refill time and mental status checks. Test-Taking Strategy:Note the subject of the question, improved tissue perfusion. This will help to identify the answer option that gives assessment data related to improved tissue perfusion, option 1. The remaining options do not provide evidence of improved tissue perfusion.

The nurse plans care understanding that which is the primary reason clients experience vasodilation in septic shock? 1. There is a release of endotoxins from bacteria. 2. There is heart failure with diminished cardiac output. 3. There is blood or fluid loss, and the body compensates by dilating the blood vessels. 4. There is an obstruction of blood flow, and the body compensates by dilating the blood vessels.

1. There is a release of endotoxins from bacteria. Rationale:A massive infection can lead to sepsis as a result of endotoxins being released, which causes vasodilation, pooling of blood, and capillary permeability. The remaining options do not provide the reason for vasodilation in septic shock.

A client diagnosed with pneumonia has been hypotensive for the last four hours, with systolic blood pressures (SBP) ranging from 80 to 100 mm Hg. The nurse is concerned that the client may be developing sepsis. What intervention would the nurse anticipate taking priority for this client? 1. Set up to begin a vasopressor drip. 2. Administer fluid resuscitation with isotonic crystalloids. 3. Continue to monitor the client's systolic blood pressure. 4. Prepare to start an arterial line to monitor the SBP more accurately.

2. Administer fluid resuscitation with isotonic crystalloids. Rationale: Pneumonia is an infectious process. The toxins released by the organism causing the infection create a reaction from the immune system to release cytokines. Cytokines cause vasodilation, causing the blood pressure to decrease. Clients may experience SBP of less than or equal to 100 mm Hg or a decrease of SBP of more than 40 mm Hg. Thus, the client needs fluid resuscitation to raise the BP. Continuing to monitor the client's systolic blood pressure delays necessary treatment. Options 1 and 4 would be done if fluid resuscitation did not assist in raising the BP. Test-Taking Strategy: Note the strategic word, priority. The question is asking for the priority among nursing interventions. Thinking about the sepsis diagnostic criteria, hypotension is among the signs and symptoms. Continuing to monitor the SBP may lead to undue client harm. The correct answer, option 2, is a realistic intervention that may improve the client's clinical status. Options 1 and 4 are interventions to be performed if the client fails to respond to fluid resuscitation.

Which finding in a postoperative client would be of concern to the nurse? 1. Urinary output of 40 mL/hr 2. Temperature of 37.6° C (99.6° F) 3. Blood pressure of 88/52 mm Hg 4. Moderate drainage on the surgical dressing

3. Blood pressure of 88/52 mm Hg Rationale: The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A falling systolic blood pressure, under 90 mm Hg, is considered reportable because it could be an indication of bleeding and potential shock. Urine output needs to be maintained at a minimum of 30 mL/hr for an adult, so 40 mL per hour is adequate. An output of less than 30 mL/hr for each of 2 consecutive hours needs to be reported to the surgeon. A temperature above 37.7° C (100° F) or below 36.1° C (97° F) is a concern and would be reportable. Moderate or light serous drainage from the surgical site is considered normal.

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased, and the blood pressure is 92/68 mm Hg. The nurse suspects which stage of shock based on this data? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2. Stage 2 Rationale: Shock is categorized by four stages. Stage 1 is characterized by restlessness, increased heart rate, cool and pale skin, and agitation. Stage 2 is characterized by a cardiac output that is less than 4 to 6 liters per minute, systolic blood pressure of less than 100 mm Hg, decreased urinary output, confusion, and cerebral perfusion pressure that is less than 70 mm Hg. Stage 3 is characterized by edema, excessively low blood pressure, dysrhythmias, and weak and thready pulses. Stage 4 is characterized as unresponsiveness to vasopressors, profound hypotension, slowed heart rate, and multiple organ failure. Most often, the client will not survive. Noting the signs of restlessness, agitation, and confusion, as well as the low blood pressure and decreased urinary output, will direct you to Stage 2 as the correct answer.

A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action would the nurse take? 1. Document these findings, which are expected. 2. Re-evaluate the neurovascular status in 1 hour. 3. Call the primary health care provider immediately. 4. Increase the rate of the intravenous nitroglycerin infusion.

3. Call the primary health care provider immediately. Rationale: The nursing interventions for the client with an intra-aortic balloon pump are the same as for any client who has had cardiovascular surgery. The peripheral circulation to the affected limb is monitored for signs of occlusion, such as coolness, mottling, pain, tingling, and decreased or absent distal pulse. Adverse changes are reported immediately. The remaining options are incorrect.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component would the nurse expect the primary health care provider to prescribe? 1. Platelets 2. Granulocytes 3. Fresh-frozen plasma 4. Packed red blood cells

3. Fresh-frozen plasma Rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It is rich in clotting factors and can be thawed quickly and transfused quickly. Platelets are used to treat thrombocytopenia and platelet dysfunction. Granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics. Packed red blood cells are a blood product used to replace erythrocytes.

After receiving Situation, Background, Assessment, Recommendation (SBAR) hand-off on a client flagged for sepsis criteria, the nurse would take what action first? 1. Notify the physician. 2. Obtain a blood glucose reading per physician order. 3. Perform an assessment of the client and obtain vital signs. 4. Access the electronic health record (EHR) and gather assessment and lab data.

3. Perform an assessment of the client and obtain vital signs. Rationale: The nurse would establish a baseline of the client's status by performing an assessment and obtaining vital signs. A client who is possibly septic may have changes in mental status, vital signs, urinary output, and cardiovascular status. Establishing a baseline is imperative to note any changes that may occur. The nurse would notify the physician if any abnormal findings warranting notification are determined, so the assessment needs to be done first. Obtaining a glucose reading can be done after the assessment is done. Although the nurse may want to look at the EHR for data to compare to current findings, the priority is to focus on the client's current status. Test-Taking Strategy: Note the strategic word, first. You must select the response that is the priority for the client. Use the steps of the nursing process; assessment of the client comes before any other step. Assessment is crucial in safely and effectively caring for the client.

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply. 1. Urine output 50 mL/hr 2. Hypoactive bowel sounds 3. Temperature of 102° F (38.9° C) 4. Heart rate of 96 beats per minute 5. Mean arterial pressure 65 mm Hg 6. Systolic blood pressure 110 mm Hg

3. Temperature of 102° F (38.9° C) 4. Heart rate of 96 beats per minute 5. Mean arterial pressure 65 mm Hg Rationale: Sepsis diagnostic criteria with regard to signs and symptoms include the following: Fever (temperature higher than 100.9° F [38.3° C]) or hypothermia (core temperature lower than 97° F [36° C]), heart rate above 90 beats per minute, tachypnea (respiratory rate above 22 breaths per minute), systolic blood pressure (SBP) less than or equal to 100 mm Hg or arterial hypotension (SBP below 90 mm Hg), MAP of less than 70 mm Hg, or a decrease in SBP of more than 40 mm Hg, altered mental status, edema or positive fluid balance, oliguria, ileus (absent bowel sounds), and decreased capillary refill or mottling of skin.

The nurse is caring for a client with sepsis. Which intervention performed by the nurse indicates an inaccurate action and the need for teaching? 1. Administering the prescribed antibiotics 2. Obtaining blood glucose readings as ordered 3. Waiting to obtain cultures until the antibiotic is complete 4. Suggesting that the physician order albumin for fluid resuscitation

3. Waiting to obtain cultures until the antibiotic is complete Rationale: Intervening early with intravenous (IV) antibiotics is crucial for clients diagnosed with sepsis. To ensure that the antibiotic will kill the microorganism causing the infection, blood cultures should be obtained before beginning IV antibiotics. The results of the culture will ensure that the correct antibiotic is prescribed. Options 1, 2, and 4 are accurate interventions. Test-Taking Strategy: Note the strategic words, need for teaching. These words indicate a negative event query and the need to select the incorrect intervention. In this case, waiting to obtain blood cultures until after the antibiotic is complete is the incorrect order, making option 3 the correct choice.

The charge nurse understands that there is a need for further teaching when the nurse caring for a client with septic shock states which of the following? 1. "Frequent assessments of mental status may be necessary." 2. "It will be important to watch the trend of the client's lab values." 3. "Blood transfusions may be needed to help with the client's coagulopathy." 4. "Administering antibiotics is the best way to correct and treat septic shock."

4. "Administering antibiotics is the best way to correct and treat septic shock." Rationale:Antibiotics are an important piece of the treatment and management of shock, but the treatment and management encompass many different interventions and methods, not just administering antibiotics. Discovering what the underlying condition is will be crucial in treating the client properly, and restoration of tissue perfusion and circulating volume must be achieved first. Options 1, 2, and 3 are correct actions.

The home health nurse visits a client recovering after an episode of cardiogenic shock secondary to an anterior myocardial infarction (MI) and provides home care instructions to the client. Which statement by the client indicates an understanding of these home care measures? 1. "I exercise every day after breakfast." 2. "I've gained 8 lb (3.6 kg) since discharge." 3. "I take an antacid when I experience epigastric pain." 4. "I have planned periods of rest at 10:00 a.m. and 3:00 p.m. daily."

4. "I have planned periods of rest at 10:00 a.m. and 3:00 p.m. daily." Rationale: The client recovering from an episode of cardiogenic shock secondary to an MI will require a progressive rehabilitation related to physical activity. The heart requires several months to heal from an uncomplicated MI. The complication of cardiogenic shock increases the recovery period for healing. Paced activities with planned rest periods will decrease the chance of experiencing angina or delayed healing. It is best to allow the meal to settle prior to activity in order to improve circulation to the heart during exercise. Epigastric pain or a weight gain of 8 lb (3.6 kg) is significant and needs to be reported to the primary health care provider, at which point follow-up should occur.

Which client would most likely be the highest risk for systemic inflammatory response syndrome (SIRS)? 1. A client admitted for new-onset seizures 2. A client admitted for new-onset diabetes mellitus 3. A client admitted for a gastrointestinal bleeding ulcer 4. A client with cancer admitted for a central line placement

4. A client with cancer admitted for a central line placement Rationale: The client with cancer is at increased risk for infection. In addition, this client is admitted for the placement of a central line, an invasive procedure. This combination would place this client at highest risk for developing SIRS secondary to an infection. Test-Taking Strategy: Note the strategic words, most likely. This will direct you to the correct option. Remember that SIRS is a systemic inflammation that occurs separate from the initially infected area.

What primary characteristic of cardiogenic shock helps determine what nursing interventions are performed? 1. Blood pools in the heart, so care is focused on diuresing. 2. Urinary output is low, so care is focused on increasing circulating volume. 3. Hypotension is severe, so care is focused on blood pressure monitoring. 4. Cardiac output is compromised, so care is focused on restoring tissue perfusion.

4. Cardiac output is compromised, so care is focused on restoring tissue perfusion. Rationale: Cardiogenic shock occurs when the heart fails to pump adequately, thus reducing cardiac output and compromising tissue perfusion. The goal of management and treatment for cardiogenic shock is to restore cardiac output and tissue perfusion; then treatment of the underlying cause can be managed. Options 1, 2, and 3 are not primary characteristics.

The nurse in the emergency department is caring for a client who was in a motor vehicle accident with subsequent internal hemorrhage. The client's mean arterial pressure (MAP) has decreased from 75 mm Hg to 60 mm Hg, the heart rate has increased from 92 beats per minute to 103 beats per minute, and the client is reporting a sensation of thirst. The nurse suspects the client may be in hypovolemic shock. Based on the subjective and objective data, the nurse would determine the client is in which stage of hypovolemic shock? 1. Initial 2. Refractory 3. Progressive 4. Compensatory

4. Compensatory Rationale: Shock is a progressive condition divided into four stages when the causatory mechanisms remain uncorrected. These four stages in order of chronicity are the initial stage, the compensatory stage, the progressive stage, and the refractory stage. A decrease in MAP of 10 to 15 mm Hg from the baseline value, increased heart rate, and a sensation of thirst are characteristic of the second stage, or the compensatory stage. Other clinical manifestations of the compensatory stage include decreased pulse pressure, mild acidosis, mild hyperkalemia, and increased stimulation of the renin-angiotensin-aldosterone system (RAAS), which contributes to decreased urine output and increased thirst. Therefore, option 4 is correct, as the client is experiencing a 15 mm Hg decrease in MAP, an increase in heart rate, and an increase in thirst sensation.

The nurse is preparing to administer intravenous fluids to a client in hypovolemic shock with significant interstitial edema. The nurse would anticipate administering which of the following solutions? 1. Lactated Ringer solution 2. 0.9% normal saline solution 3. Packed red blood cells (PRBCs) 4. Normal serum human albumin

4. Normal serum human albumin Rationale: Hypovolemic shock results from inadequate circulating volume that causes a decrease in preload and cardiac output. The decrease in cardiac output and associated hypotension result in decreased tissue perfusion and hypoxic cell injury as the blood volume is inadequate to perfuse tissues. Treatment of hypovolemic shock consists of controlling the source of blood loss and then administering fluids to replace the inadequate circulating volume. The different kinds of solutions used to treat hypovolemic shock include colloids, crystalloids, and blood products. Colloids are used in the treatment of hypovolemic shock with associated interstitial edema, as colloids increase the serum colloid osmotic pressure in the intravascular space, which pulls fluid from the interstitium into the vascular space. Examples of colloids include normal human serum albumin, dextran, and hetastarch. Options 1 and 2 are examples of crystalloid solutions. Option 3 is a blood product. Since the client is experiencing significant interstitial edema, the nurse would expect a colloid solution to be ordered. Therefore, option 4 is the correct answer.

The nurse is assisting in caring for a client diagnosed with multiple organ dysfunction syndrome (MODS). Which client problem would the nurse assign as the highest priority for this client? 1. Anxiety 2. Activity intolerance 3. Risk for ineffective coping 4. Poor or imbalanced nutrition

4. Poor or imbalanced nutrition Rationale:Interventions that surround the care of a client with MODS include support of the failing organ systems, maintenance of tissue oxygenation, promoting nutrition to meet metabolic needs, and care, education, and comfort measures. Addressing the client's psychological needs is important; however, providing care to support the client's organ systems is essential. Test-Taking Strategy:Note the strategic words, highest priority. Each problem may apply and may be important to meet the client's needs, but the highest priority would be given to interventions that support the client's organ systems; therefore, option 4 is the correct choice.

The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which assessment finding would be indicative of further fluid volume deficit? 1. 4+ edema noted in lower extremities 2. Crackles auscultated from lung bases to apices 3. Blood pressure rises from 116/68 to 118/74 mm Hg 4. Pulse rate increases from 100 beats/min to 136 beats/min

4. Pulse rate increases from 100 beats/min to 136 beats/min Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for decreases in fluid volume. Options 1 and 2 may be noted in fluid overload. A low blood pressure is expected in a postoperative client who lost a significant amount of blood.

The nurse is assisting in caring for a client with multiple organ dysfunction syndrome (MODS). The nurse understands that which intervention is most important in the care of clients with this syndrome? 1. Treatment of the infection 2. Maintaining tissue oxygenation 3. Prevention and early identification 4. Supporting the failing organ systems

4. Supporting the failing organ systems Rationale: Prevention and early identification of sepsis are the most effective interventions, but when sepsis and a systemic inflammatory response have already occurred, the client who has organ dysfunction needs to be treated and managed to support the organ systems that are failing. Test-Taking Strategy: Note the strategic words, most important. The client already has MODS, so thinking about the pathophysiology of this will help you determine that option 4 is the correct response. Treatment of the infection is too late; the client already has organ dysfunction. Prevention or early identification is incorrect because that should have been done to prevent the client from becoming septic. Option 2 could be correct, but maintaining tissue oxygenation would be accomplished under the same intervention as option 4, the umbrella option of supporting the failing organ systems.

A client is admitted after an accidental chemical ingestion. The nurse notes the following findings on assessment: dyspnea, pulse oximetry of 90% on 4 L/minute via nasal cannula, and bilateral lower lobe diminished breath sounds. The nurse analyzes these findings as indicating which priority client need? 1. Fluid restriction 2. High-Fowler position 3. Chest-ray and laboratory studies 4. Treatment for systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome

4. Treatment for systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome Rationale: SIRS is a systemic inflammatory response that results from an infection, trauma, or perfusion deficit. SIRS affects organs separate from the initial affected area. The signs and symptoms the client is portraying are associated with acute respiratory distress syndrome (ARDS), a complication of SIRS, and treatment needs to be instituted. Fluid restriction would worsen the condition and intravenous fluids may be prescribed. A High-Fowler position could place pressure on the diaphragm worsening the dyspnea. A chest x-ray and laboratory studies may be prescribed but treatment needs to be instituted as the priority.

You're providing care to four patients. Select all the patients who are at risk for developing sepsis: A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer. All the answers are correct. All the patients have risk factors for developing sepsis. Remember the mnemonic: Septic.....Suppressed immune system (AIDS/HIV, immunosuppressive therapy, steroids, chemo, pregnancy, malnutrition)....Extreme age (infants and elderly)...Post-op (surgical/invasive procedures)....Transplant recipients.....Indwelling devices (Foley catheter, central lines, trachs).....Chronic diseases (diabetes, hepatitis, alcoholism, renal insufficiency)

You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? Select all that apply: A. Blood pressure 69/38 B. Heart rate 170 bpm C. Blood pressure 250/120 D. Heart rate 29 E. Warm and dry extremities F. Cool and clammy extremities G. Temperature 104.9 'F H. Temperature 95 'F

A. Blood pressure 69/38 D. Heart rate 29 E. Warm and dry extremities H. Temperature 95 'F The answers are A, D, E, and H. Hallmark signs and symptoms of neurogenic shock are: hypotension, bradycardia, hypothermia, warm/dry extremities (this is due to the vasodilation and blood pooling and will be found in the extremities).

Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: A. Blood pressure of 70/34 after the fluid bolus B. Serum lactate less than 2 mmol/L C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement D. Central venous pressure (CVP) of 18

A. Blood pressure of 70/34 after the fluid bolus C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement The answers are A and C. To know if the patient is progressing to septic shock, you need to think about the hallmark findings associated with this condition. Septic shock is characterized by major persistent hypotension (<90 SBP) that doesn't respond to IV fluids (refractory hypotension), and the patient needs vasopressors (ex: Norepinephrine) to maintain a mean arterial pressure greater than 65 and their serum lactate is greater than 2 mmol/L. A serum lactate greater than 2 indicates the cell's tissue/organs are not functioning properly due to low oxygen; hence tissue perfusion is poor due to the low blood pressure and mean arterial pressure.

In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is occurring: A. Loss of vasomotor tone B. Increase systemic vascular resistance C. Decrease in cardiac preload D. Increase in cardiac afterload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities

A. Loss of vasomotor tone C. Decrease in cardiac preload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities The answers are A, C, E, and F. Massive vasodilation is occurring in the body and this is due to the loss of vasomotor tone (remember the sympathetic nervous system loses its ability to stimulate nerves that regular the diameter of vessels....so vessels are relaxed). This will DECREASE (NOT increase) systemic vascular resistance (which will decrease cardiac afterload) and the blood pressure will fall. Furthermore, there is pooling of venous blood in the extremities because there isn't any pressure to push it back to the heart. This will cause a decrease in venous blood return to the heart. When this occurs it will decrease cardiac preload (the amount the ventricle stretch at the end of diastole). All of this together will decrease the amount of blood the heart can pump per minute....hence the cardiac output and shock will occur.

Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply: A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L D. Blood glucose 120 mg/dL E. CVP (central venous pressure) less than 2 mmHg

A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L E. CVP (central venous pressure) less than 2 mmHg The answers are A, B, C, and E. When answering this question, select the options that would indicate the body's organs/tissues are NOT being perfused adequately. A MAP should be 65 or greater for proper tissue perfusion to occur. Urinary output should be at least 30 mL/hr. Serum lactate should be less than 2 mmoL/L....if it's high this indicates cells are not receiving enough oxygen due to low tissue perfusion. A central venous pressure (CVP) should be greater than 2 mmHg. This shows the filling pressure in the right side of the heart. If this number is low there is not enough fluid filling in the heart to maintain cardiac output. This occurs in septic shock due to hypovolemia from increased capillary permeability where fluid shifted from the intravascular to the interstitial space.

A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient? A. Modified Trendelenburg B. Trendelenburg C. High Fowler's D. Supine

A. Modified Trendelenburg The answer is A. Modified Trendelenburg position is where the patient is supine with their legs elevated at 45 degrees. This will help increase venous return to the heart (hence increase preload), which will help increase cardiac output.

You're developing a nursing plan of care for a patient with neurogenic shock. As the nurse, you know that due to venous blood pooling from vasodilation a deep vein thrombosis can occur in this type of shock. A patient goal is that the patient will be free from the development of a deep vein thrombosis. Select all the nursing interventions below that can help the patient meet this goal: A. Perform range of motion exercises daily. B. Place a pillow underneath the patient knees as needed. C. Administer anticoagulants as scheduled per physician's order. D. Apply compression stockings daily.

A. Perform range of motion exercises daily. C. Administer anticoagulants as scheduled per physician's order. D. Apply compression stockings daily. The answers are A, C, and D. Option B would impede blood flow and increase the risk of a DVT. The other options would help prevent a DVT.

The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A. The patient's blood pressure changes from 75/48 to 110/82. B. Patient's CVP 2 mmHg C. Patient's skin is warm and flushed. D. Patient's urinary output is 20 mL/hr.

A. The patient's blood pressure changes from 75/48 to 110/82. The answer is A. In septic shock, the first treatment is to try to maintain tissue perfusion with fluids. If that doesn't work to increase the blood pressure and maintain perfusion, vasopressors will be used next. In septic shock, the intravascular space will be depleted of fluid due to an increase in capillary permeability. This will lead to hypovolemia, which will decrease blood pressure and lead to a decrease in blood flow to organs/tissue. If the blood pressure increases to a normal state, that tells us the fluids are working.

A patient is being treated for cardiogenic shock. Which statement below best describes this condition? Select all that apply: A. "The patient will experience an increase in cardiac output due to an increase in preload and afterload." B. "A patient with this condition will experience decreased cardiac output and decreased tissue perfusion." C. "This condition occurs because the heart has an inadequate blood volume to pump." D. "Cardiogenic shock leads to pulmonary edema."

B. "A patient with this condition will experience decreased cardiac output and decreased tissue perfusion." D. "Cardiogenic shock leads to pulmonary edema." The answers are: B and D. Cardiogenic shock occurs when the heart can NOT pump enough blood to meet the perfusion needs of the body. The cardiac output will be DECREASED, which will DECREASE tissue perfusion and cause cell injury to organs/tissues. In this condition, the heart is WEAK and can't pump blood out of the heart. This can be due to either a systolic (contraction) or diastolic (filling) issue along with a structural or dysrhythmia issue. In cardiogenic shock, there is NOT an issue with blood volume, but there is a problem with the heart itself.

If a patient has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of volume loss this patient has experienced? A. 25% B. 40% C. 30% D. 10%

B. 40% The answer is B. This patient has lost 40% of blood volume. Based on this amount of fluid loss, this patient would be in class III (stage 3 of hypovolemic shock). Class III occurs when volume loss is 30-40% or 1,500-2,000 mL in an adult.

You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply: A. A 36-year-old with a spinal cord injury at L4. B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. D. A 55-year-old patient who is reporting seeing green halos while taking Digoxin.

B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. The answers are B and C. Any patient who has had a cervical or upper thoracic (above T6) spinal cord injury, receiving spinal anesthesia, or taking drugs that affect the autonomic or sympathetic nervous system is at risk for developing neurogenic shock.

Select all the fluid types below that are considered colloids? A. Fresh Frozen Plasma B. Albumin C. Normal Saline D. Lactated Ringer's E. Hetastarch F. Platelets The answers are B and E. These are colloid solutions. Options C and D are considered crystalloid solutions, and options A and F are blood products.

B. Albumin E. Hetastarch The answers are B and E. These are colloid solutions. Options C and D are considered crystalloid solutions, and options A and F are blood products.

A patient has a 10% loss of their blood volume. Select all the signs and symptoms this patient may present with? A. Cool, clammy skin B. Blood pressure within normal limits C. Anxiety D. Capillary refill less than 2 seconds E. Urinary output greater than 30 mL/hr F. Mild tachycardia

B. Blood pressure within normal limits D. Capillary refill less than 2 seconds E. Urinary output greater than 30 mL/hr The answers are: B, D, and E. The body can compensate for a volume loss of <15% to maintain cardiac output. Therefore, the patient will be asymptomatic until blood loss is greater than 15% and you would select normal findings for this question, which are: blood pressure within normal limits, capillary refill less than 2 seconds, urinary output greater than 30 mL/hr. Anxiety, cool/clammy skin, and mild tachycardia may present when volume loss is higher.

Your patient is started on an IV antibiotic to treat a severe infection. During infusion, the patient uses the call light to notify you that she feels a tight sensation in her throat and it's making it hard to breathe. You immediately arrive to the room and assess the patient. While auscultating the lungs you note wheezing. You also notice that the patient is starting to scratch the face and arms, and on closer inspection of the face you note redness and swelling that extends down to the neck and torso. The patient's vital signs are the following: blood pressure 89/62, heart rate 118 bpm, and oxygen saturation 88% on room air. You suspect anaphylactic shock. Select all the appropriate interventions for this patient: A. Slow down the antibiotic infusion B. Call a rapid response C. Place the patient on oxygen D. Prepare for the administration of Epinephrine

B. Call a rapid response C. Place the patient on oxygen D. Prepare for the administration of Epinephrine Option A is wrong because the nurse should STOP the infusion, not slow it down because this could be the reason for the anaphylactic reaction. The nurse would want to call a rapid response, place the patient on oxygen, and prepare for the administration of Epinephrine. This drug is the first-line treatment for anaphylactic shock. It will increase the blood pressure, decrease swelling, and dilate the airway.

Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A. Administer Norepinephrine before attempting a fluid resuscitation. B. Collect cultures and then administer IV antibiotics. C. Check blood glucose levels before starting any other treatments. D. Administer Drotrecogin Alpha within 48-72 hours.

B. Collect cultures and then administer IV antibiotics. The answer is B. This is the only correct option. Option A is wrong because fluids are administered first, and if they don't work vasopressors (Norepinephrine) is administered. Option C is wrong because although blood glucose levels should be measured, it does not take precedence over other treatments. Option D is wrong because Drotrecogin alpha should be given within 24-48 hours of septic shock to be the most effective.

Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? A. Low-dose corticosteroids B. Crystalloids IV fluid bolus C. Norepinephrine D. 2 units of Packed Red Blood Cells

B. Crystalloids IV fluid bolus The answer is B. The first treatment in regards to helping maintain tissue perfusion is fluid replacement with either crystalloid or colloid solutions. THEN vasopressors like Norepinephrine are ordered if the fluids don't help.

You're providing education to a patient, who has a severe peanut allergy, on how to recognize the signs and symptoms of anaphylactic shock. Select all the signs and symptoms associated with anaphylactic shock: A. Hyperglycemia B. Difficulty speaking C. Feeling dizzy D. Hypertension E. Dyspnea F. Itchy G. Vomiting and Nausea H. Fever I. Slow heart rate

B. Difficulty speaking C. Feeling dizzy E. Dyspnea F. Itchy G. Vomiting and Nausea Patients who are in anaphylactic shock will have signs and symptoms associated with the effects of histamine. Remember histamine affects the respiratory, cardiac, GI and skin. The patient can have the following: Respiratory: dyspnea and wheezing (bronchoconstriction), swelling of upper airways due to edema "tightness"...can't speak, coughing, stuffy nose, watery eyes, Cardiac: tachycardia, hypotension (vasodilation)...loss of consciousness, dizzy, GI: vomiting, nausea, pain, Skin: vasodilation...red, swollen, itchy, hives

A patient in neurogenic shock is ordered intravenous fluids due to severe hypotension. During administration of the fluids the nurse will monitor the patient closely and immediately report? A. Increase in blood pressure B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) C. Urinary output of 300 mL in the past 5 hours D. Mean arterial pressure (MAP) 85 mmHg

B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) The answer is B. Option B would indicate the patient is in fluid volume overload. Remember that patients in neurogenic shock usually have a normal blood volume. If fluids are ordered to help increase the blood pressure, they should be used with extreme caution because fluid overload can occur. An increase in the CVP and PAWP would indicate this. These pressures show the filling pressure in the heart.

A patient with cardiogenic shock has a blood pressure of 70/38. In addition, the patient is experiencing dyspnea with a respiratory rate of 32 breaths per minute and has an oxygen saturation of 82% on room air. On auscultation, you note crackles throughout the lung fields. You notify the physician. What order below would you ask for an order clarification? A. Dopamine IV stat B. Normal saline IV bolus stat C. Furosemide IV stat D. Place patient on CPAP (continuous positive airway pressure)

B. Normal saline IV bolus stat The answer is B. This patient with cardiogenic shock is experiencing a decrease in cardiac output (hence the blood pressure), so an order for Dopamine can help provide a positive inotropic effect (increase the contractility of the heart which will increase stroke volume and cardiac output). The patient is also experiencing pulmonary congestion due to the cardiogenic shock. The heart is failing to pump blood forward, so it is backing up in the lungs. This is leading to an increased respiratory rate, dyspnea, and low oxygen saturation. The order for Furosemide (which is a diuretic) will help remove the extra fluid volume from the lungs and the CPAP (continuous positive airway pressure) will help with oxygenation. The nurse would question the order for a normal saline IV bolus. This bolus would add more fluid to the lungs and further congest the fluids.

You're assessing your patient with cardiogenic shock, what signs and symptoms do you expect to find in this condition? Select all that apply: A. Warm, flushed skin B. Prolonged capillary refill C. Urinary output >30 mL/hr D. Systolic blood pressure <90 mmHg E. Crackles in lung fields F. Dyspnea D. Decreased BUN and creatinine G. Strong peripheral pulses H. Chest pain

B. Prolonged capillary refill D. Systolic blood pressure <90 mmHg E. Crackles in lung fields F. Dyspnea H. Chest pain The answers are B, D, E, F, and H. Signs and symptoms of cardiogenic shock will be related to LOW cardiac output and decreased perfusion to organs/tissues. Capillary refill will be prolonged >2 seconds, Urinary output will be <30 mL/hr, systolic blood pressure will be <90 mmHg, pulmonary edema will present with fluid in the lungs (hence crackles in the lungs), dyspnea, chest pain (due to decreased blood flow to the heart muscle).

A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock? A. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension. B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. C. The patient's parasympathetic nervous system is being unopposed by the sympathetic nervous system, which leads to severe hypotension. D. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension.

B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. The answer is B. The sympathetic nervous system (which is a division of the autonomic nervous system) is unable to stimulate the nerves that regulate the diameter of the blood vessels (there's a loss of vasomotor tone). So, now the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur.

During anaphylactic shock the mast cells and basophils release large amounts of histamine. What effects does histamine have on the body during anaphylactic shock? Select all that apply: A. Decreases capillary permeability B. Vasodilation of vessels C. Decreases heart rate D. Shifts intravascular fluid to interstitial space E. Constricts the airways F. Stimulates contraction of GI smooth muscles G. Inhibits the production of gastric secretions H. Itching

B. Vasodilation of vessels D. Shifts intravascular fluid to interstitial space E. Constricts the airways F. Stimulates contraction of GI smooth muscles H. Itching Histamine: INCREASES capillary permeability (not decreases) by shifting the intravascular fluid to the interstitial space...this causes swelling and lowers blood pressure, vasodilates vessels...this lower blood pressure and causes red skin, increases heart rate (not decreases), constricts the airway...this causes difficulty breathing and wheezes, stimulates contraction of GI smooth muscles and stimulates (not inhibits) the production of gastric secretions...this leads to vomiting, nausea, and pain, and there is also itching.

Select all the conditions below that increases a patient's risk for absolute hypovolemic shock: A. Burns B. Vomiting C. Long bone fracture D. Surgery E. Diarrhea F. Sepsis

B. Vomiting D. Surgery E. Diarrhea The answers are: B, D, and E. Vomiting, diarrhea, and surgery can all increase the loss of fluid volume outside the body, which are absolute hypovolemic shock types. Burns, long bone fracture, and sepsis can lead to an inside fluid shift of fluid from the intravascular system and are relative hypovolemic shock types.

A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply: A. Urinary output of 60 mL over 4 hours B. Warm and flushed skin C. Tachycardia D. Bradypnea

B. Warm and flushed skin C. Tachycardia The answers are B and C. In the early or compensated stage of septic shock, the patient is in a hyperdynamic state. This is different from the other types of shock like hypovolemic or cardiogenic (vasoconstriction is occurring in these types of shock). In septic shock, vasodilation is occurring and this leads to WARM and FLUSHED skin in the early stage. However, in the late stage the skin will be cool and clammy. Tachycardia and TACHYpnea (not bradypnea) occurs in the early stage too as a compensatory mechanism. Oliguria (option A) is in the late stage or uncompensated when the kidneys are starting to fail.

A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to? A. Rapidly infuse the fluids B. Warm the fluids C. Change tubing in between bags D. Keep the patient supine

B. Warm the fluids The answer is B. It is very important when giving large amount of fluids that the nurse ensures the fluids are warm. WHY? To prevent the patient from developing hypothermia. If this develops, clotting enzymes can become altered along with leukopenia and thrombocytopenia. Keep the patient warm, but not too hot.

A patient is diagnosed with septic shock. As the nurse you know this is a __________ form of shock. In addition, you're aware that __________ and _________ are also this form of shock. A. obstructive; hypovolemic and anaphylactic B. distributive; anaphylactic and neurogenic C. obstructive; cardiogenic and neurogenic D. distributive; anaphylactic and cardiogenic

B. distributive; anaphylactic and neurogenic The answer is B. Septic shock is a form of distributive shock. This means there is an issue with the distribution of blood flow in the small blood vessels of the body. This results in a diminished supply of blood to the body's tissues and organs. Anaphylactic and neurogenic shock are also a type of distributive form of shock. Septic shock isn't occurring due to an issue with cardiac output, which occurs in hypovolemic and cardiogenic shock.

A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to? A. An increase in cardiac preload B. An increase in stroke volume C. A decrease in cardiac preload D. A decrease in cardiac contractility

C. A decrease in cardiac preload The answer is C. Because there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart (this is the amount of blood draining back to the heart). Hence, this will lead to a DECREASE in preload. Remember preload is the amount the ventricles stretch once their filled with blood. The ventricle won't be stretching too much because there isn't enough fluid to fill them. This will decrease stroke volume and in turn decrease cardiac output.

A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT? A. Adenosine B. Warfarin C. Atropine D. Norepinephrine

C. Atropine The answer is C. Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn't working the way it should, it can NOT oppose the parasympathetic system....which will take over and lead to bradycardia.

A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to? A. Collect a urine sample B. Obtain an EKG C. Establish 2 large-bore IV access sites D. Place a warming blanket on the patient

C. Establish 2 large-bore IV access sites The answer is C. This patient is at major risk for hypovolemic shock due to the multiple long bone fractures and an internal abdominal injury (this can lead to relative hypovolemic shock...where fluid is loss inside the body). The patient is already showing signs and symptoms of hypovolemic shock. Therefore, it should be a nursing priority to establish IV access (at least two sites should be obtained using a large-bore cannula....18 gauge or higher). Fluids and possibly blood products will need to be given to this patient along with pain medication etc.

One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply: A. Temperature 104.8 'F B. Heart rate 40 bpm C. Heart rate 140 bpm D. Anxiety, restlessness E. Urinary output 15 mL/hr F. Blood pressure 70/56 G. Pale, cool skin H. Weak peripheral pulses I. Blood pressure 220/106

C. Heart rate 140 bpm D. Anxiety, restlessness E. Urinary output 15 mL/hr F. Blood pressure 70/56 G. Pale, cool skin H. Weak peripheral pulses The answers are: C, D, E, F, G, and H. Signs and symptoms of hypovolemic shock include: tachycardia, hypotension, increased respiratory rate, cool/pale/clammy skin, anxiety, decreased urinary output (normal UOP is >30 mL/hr), weak peripheral pulses

Your patient is having a sudden and severe anaphylactic reaction to a medication. You immediately stop the medication and call a rapid response. The patient's blood pressure is 80/52, heart rate 120, and oxygen saturation 87%. Audible wheezing is noted along with facial redness and swelling. As the nurse you know that the first initial treatment for this patient's condition is? A. IV Diphenhydramine B. IV Normal Saline Bolus C. IM Epinephrine D. Nebulized Albuterol

C. IM Epinephrine Epinephrine will cause vasoconstriction (this will increase the blood pressure and decrease swelling) and bronchodilation (this will dilate the airways). This patient's cardiovascular and respiratory system is compromised. Therefore, epinephrine will provide fast relief with anaphylaxis.

7. Which patient below is at MOST risk for developing cardiogenic shock? A. A 52-year-old male who is experiencing a severe allergic reaction from shellfish. B. A 25-year-old female who has experienced an upper thoracic spinal cord injury. C. A 72-year-old male who is post-op from a liver transplant. D. A 49-year-old female who is experiencing an acute myocardial infarction.

D. A 49-year-old female who is experiencing an acute myocardial infarction. The answer is D. An acute MI (heart attack) is the main cause of cardiogenic shock. It happens because a coronary artery has become blocked. Coronary arteries supply the heart muscle's cells with oxygenated blood. If they don't receive this oxygenated blood they will die, which causes the heart muscle to quit working (hence pumping efficiently). When the heart muscle fails to pump efficiently, cardiac output fails and cardiogenic shock occur.

A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? A. Fungus B. Virus C. Parasite D. Bacteria

D. Bacteria The answer is D. Gram-positive or gram-negative bacteria are the MOST common cause of sepsis.

During what stage (or class) of hypovolemic shock does the sympathetic nervous system attempt to maintain cardiac output? A. I B. III C. IV D. II .

D. II The answer is D. During stage 2 or class II of hypovolemic shock, the cardiac output is falling even more due to volume loss. This is when the patient has lost 15-30% of volume. During this time the sympathetic nervous system will take over and attempt to maintain cardiac output.

You're providing care to a patient in anaphylactic shock. What is NOT a typical medical treatment for this condition, and if ordered the nurse should ask for an order clarification? A. IV Diphenhydramine B. Epinephrine C. Corticosteroids D. Isotonic intravenous fluids E. IV Furosemide

E. IV Furosemide Furosemide is a loop-diuretic. This medication removes extra fluid from the blood volume. This is NOT used as treatment in anaphylactic shock. Patients with this condition actually need fluids because of the shift of fluid from the intravascular space to the interstitial space. All the other medications may be ordered for this condition depending on the patient's condition.

True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. True False

False The answer is FALSE. This statement is incorrect because there is a DECREASE (not increased) systemic vascular resistance in septic shock due to vasodilation. In septic shock, vasodilation is system wide. In addition, septic shock causes increased capillary permeability and thrombi formation in the microcirculation throughout the body. The vasodilation, increased capillary permeability, and clot formation in the microcirculation all leads to a decrease in tissue perfusion. This causes organ and tissue dysfunction, hence septic shock.

True or False: A patient with acute pancreatitis is presenting with Turner and Cullen's Sign. This patient is at risk for absolute hypovolemic shock. True False

False The answer is FALSE: The statement should read: A patient with acute pancreatitis is presenting with Turner and Cullen's Sign. This patient is at risk for RELATIVE (not absolute) hypovolemic shock. Relative hypovolemic shock is an INSIDE fluid shift from the intravascular system, which occurs in cases of acute pancreatitis. If a patient has Turner's Sign (bruising on the flanks) or Cullen's Sign (bruising around the umbilicus) this can indicate internal hemorrhage and this places the patient at risk for RELATIVE hypovolemic shock. Absolute hypovolemic shock occurs when there is an OUTSIDE fluid shift out of the body from the intravascular system.

True or False: Hypovolemic shock occurs where there is low fluid volume in the interstitial compartment. True False

False Answer: FALSE Hypovolemic shock occurs where there is low fluid volume in the INTRAVASCULAR (not interstitial) system.

True or False: The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes. True False

False Answer: FALSE....the statement should say: The sympathetic (NOT parasympathetic) nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

You are caring for a patient who suffered a motor vehicle accident and now has a severe injury to his spinal cord. He's diagnosed with neurogenic shock. What nursing interventions should you complete? (Select all that apply) a. Administer atropine b. Administer a vasodilator c. Administer a vasopressor d. Move the patient to an upright position e. Monitor vital signs

a. Administer atropine c. Administer a vasopressor e. Monitor vital signs Answer: A, C, and E — Patients with neurogenic shock should not be given vasodilators that will widen blood vessels and cause further hypotension. Also, never move a patient with a spinal cord injury. Atropine will correct the patient's bradycardia. A vasopressor will constrict blood vessels which will increase the blood pressure. And finally, a patient with shock should always have vital signs closely monitored.