MS exam 2 practice q

A patient's blood pressure is 172/94 mm Hg. What would the nurse calculate as being this patient's mean arterial pressure (MAP)? 80 100 120 160

120

The nurse is assisting in the care of several patients in the critical care unit. Which patient is most at risk for developing multiple organ dysfunction syndrome (MODS)? A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection

A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection

The nurse is caring for a group of patients. Which patient is at the highest risk for the development of septic shock? A patient who sustained abdominal trauma A patient with biliary obstruction A patient with gastrointestinal bleeding A patient with a ruptured abdominal aneurysm

A patient with biliary obstruction

While obtaining objective data during the assessment of the cardiovascular system of a patient, the nurse identifies that which findings will require further evaluation? Select all that apply. A thready pulse is present. Hands and feet are cold to touch. Edema is absent in the extremities. Veins in the neck are not distended. Capillary refill takes longer than two seconds.

A thready pulse is present. Hands and feet are cold to touch. Capillary refill takes longer than two seconds.

You're providing care to a patient who has experienced a 45% loss of their fluid volume and is experiencing hypovolemic shock. The patient has hemodynamic monitoring and fluid resuscitation is being attempted. Which finding indicates the patient is still in hypovolemic shock? A. Low central venous pressure B. High pulmonary artery wedge pressure C. Elevated mean arterial pressure D. Low systemic vascular resistance

A. Low central venous pressure

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

A patient is brought to the emergency department (ED) after multiple bee stings. On assessment, the nurse finds that the patient has edema on the lips and tongue as well as chest pain, dizziness, wheezing, and stridor. What type of shock should the nurse document this as? Septic shock Obstructive shock Neurogenic shock Anaphylactic shock

Anaphylactic shock

An obstetric patient who had a placental abruption is experiencing acute hemorrhage due to disseminated intravascular coagulation (DIC). Which action is the highest priority for the nurse? Maintaining the patient's intake and output accurately. Instructing the patient regarding measures to prevent bleeding Assessing the patient for signs and symptoms of hypovolemic shock Assessing the patient's discharge needs in regards to caring for a newborn

Assessing the patient for signs and symptoms of hypovolemic shock

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."

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."

A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication?* A. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater." B. "This medication causes vasodilation and decreases systemic vascular resistance." C. "It is used when fluid replacement is not unsuccessful." D. "It is considered a vasopressor."

B. "This medication causes vasodilation and decreases systemic vascular resistance."

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

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

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

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

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

You're caring for a patient with cardiogenic shock. Which finding below suggests the patient's condition is worsening? Select all that apply: A. Blood pressure 95/68 B. Urinary output 20 mL/hr C. Cardiac Index 3.2 L/min/m2 D. Pulmonary artery wedge pressure 30 mmHg

B. Urinary output 20 mL/hr D. Pulmonary artery wedge pressure 30 mmHg

A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply: A. Absolute hypovolemia B. Vasodilation C. Increased capillary permeability D. Increased systemic vascular resistance E. Clot formation in microcirculation F. A significantly decreased cardiac output

B. Vasodilation C. Increased capillary permeability E. Clot formation in microcirculation

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 H. Inhibits the production of gastric secretions I. Itching

B. Vasodilation of vessels D. Shifts intravascular fluid to interstitial space E. Constricts the airways I. Itching

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

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

A patient admitted to the hospital after a motor vehicle accident (MVA) is in hypovolemic shock. On examination, the nurse finds that the patient is becoming anxious, and the urine output is decreasing. What appropriate action should the nurse perform? Begin crystalloid fluid replacement. Start fluids only if deterioration occurs. Prepare for administering blood products. Wait for the patient to compensate naturally.

Begin crystalloid fluid replacement.

A patient with abdominal trauma is at risk for the development of hypovolemic shock. Which assessment finding by the nurse would indicate that the patient is developing this condition? Respiratory rate of 16 breaths/minute Heart rate of 58 beats/minute Blood pressure of 80/42 mm Hg Increased pulse pressure

Blood pressure of 80/42 mm Hg

Which medications below are used in cardiogenic shock that provide a positive inotropic effect on the heart? Select all that apply: A. Nitroglycerin B. Sodium Nitroprussidde C. Dobutamine D. Norepinephrine E. Dopamine

C. Dobutamine E. Dopamine

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

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

. 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

Based on this scenario, what stage of shock is this patient most likely experiencing: A 74-year-old patient is extremely confused and does not respond to commands or stimulation. The patient respiratory rate is 28 and labored, oxygen saturation 86%, heart rate 120, blood pressure 70/40, mean arterial pressure is 50 mmHg, and temperature is 97 'F. The patient's heart rhythm is atrial fibrillation. The patient's urinary output is 5 mL/hr. The patient's labs: blood pH 7.15, serum lactate 15 mmol/L, BUN 55 mg/dL, Creatinine 6 mg/dL. In addition, the patient is now starting to have slight oozing of blood around puncture sites. A. Initial B. Proliferative C. Progressive D. Compensatory

C. Progressive

You're caring for a patient who is experiencing shock. Which lab result below demonstrates that the patient's cells are using anaerobic metabolism? A. Ammonia 18 µ/dL B. Potassium 4.5 mEq/L C. Serum Lactate 9 mmol/L D. Bicarbonate 23 mEq/L

C. Serum Lactate 9 mmol/L

The nurse is caring for a 55-yr-old man who has a catheter in the right radial artery for invasive arterial blood pressure monitoring after abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention? Arterial pressure bag is inflated to 250 mm Hg. Calculated mean arterial pressure is 74 mm Hg. Patient's head of bed elevation is at 30 degrees. Capillary refill time in the right hand is 5 seconds.

Capillary refill time in the right hand is 5 seconds.

The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored? Select all that apply. Urine output Cardiac output White blood cells Available hemoglobin Arterial oxygen saturation

Cardiac output Available hemoglobin Arterial oxygen saturation

Which type of shock is associated with hyperglycemia, presence of pulmonary infiltrates in chest x-ray and increased levels of blood urea nitrogen (BUN)? Septic Obstructive Cardiogenic Hypovolemic

Cardiogenic

A patient presents to the emergency department (ED) in a state of shock. On assessment, the nurse finds that the patient is cyanotic and has crackles on auscultation of the lungs. As which type of shock will the nurse classify this? Neurogenic shock Cardiogenic shock Hypovolemic shock Anaphylactic shock

Cardiogenic shock

A patient is scheduled to have an insertion of a pulmonary artery catheter for hemodynamic monitoring. What conditions should the nurse recognize are contraindicated for insertion of the catheter? Select all that apply. Coagulopathy Cardiogenic shock Fulminant myocarditis Endocardial pacemaker Mechanical tricuspid valve

Coagulopathy Endocardial pacemaker Mechanical tricuspid valve

A patient with severe anaphylactic reaction is experiencing hypovolemic shock. What physiologic change will help the patient to compensate for the hemodynamic imbalance? Activation of neurons Stimulation of protein kinase Constriction of peripheral blood vessels Suppression of the sympathetic nervous system

Constriction of peripheral blood vessels

What is the function of a transducer? Helps locate the phlebostatic axis Transmits electronic signal as a pressure wave Converts pressure waves into an electronic signal Changes zero reference point to atmospheric pressure

Converts pressure waves into an electronic signal

During what stage of shock does the body attempt to utilize the hormonal, neural, and biochemical responses of the body? A. Refractory B. Initial C. Proliferative D. Compensatory

D. Compensatory

A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT?* A. IV corticosteroids B. Colloids C. Dobutamine D. Norepinephrine

D. Norepinephrine

A patient is admitted to the intensive care unit following an abdominal aortic aneurysm resection. The pulmonary artery catheter shows the following readings: PAD, 14; PAWP, 18; CVP, 17. The patient's heart rate is 110 beats/minute. Intravenous (IV) fluid is running at 150 mL/hr. What orders would the nurse anticipate receiving from the health care provider? Monitor hemodynamic parameters again in one hour. Maintain IV fluids at 150 mL/hour until the tachycardia resolves. Decrease IV fluids to 125 mL/hour, and recheck hemodynamic parameters. Increase IV fluids to 175 mL/hour to resolve the tachycardia and compensate for blood loss.

Decrease IV fluids to 125 mL/hour, and recheck hemodynamic parameters. (theyre high which indicates fld overload)

When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? Increased serum albumin Decreased respiratory compliance Increased gastrointestinal (GI) motility Decreased blood urea nitrogen (BUN)/creatinine ratio

Decreased respiratory compliance

A patient is showing signs of anaphylactic shock from an insect sting. Which health care provider's order does the nurse implement first ? Diphenhydramine 50 mg IV Oxygen via nasal cannula at 3 L Epinephrine 1:1000, 0.5 mg IM Normal saline intravenous (IV) to run at 150 mL/hr

Epinephrine 1:1000, 0.5 mg IM

The release of platelet-activating factors in patients who have sepsis triggers which response? Third spacing Formation of microthrombi Increased capillary permeability Decreased production of cytokines

Formation of microthrombi

Which medication would the nurse administer to treat renal complications associated with systemic inflammatory response syndrome (SIRS)? Antacids Sucralfate Furosemide Omeprazole

Furosemide

A patient with abdominal trauma is at a risk for hypovolemic shock. Which clinical manifestations assessed by the nurse indicate the patient is developing shock? Select all that apply. Heart rate of 120 beats/minute Urine output 7 mL/hr Blood pressure 150/78 mm Hg Respiratory rate of 20 breaths/minute Decreased level of consciousness

Heart rate of 120 beats/minute Urine output 7 mL/hr Decreased level of consciousness

The nurse is mentoring a graduate nurse and is explaining the use of fluids in a patient who is experiencing hypovolemic shock. Which of the following fluids increases osmotic pressure to provide rapid volume expansion? Lactated Ringer's 3% sodium chloride Fresh frozen plasma Human serum albumin

Human serum albumin

The nurse would recognize which clinical manifestation as suggestive of sepsis? Sudden diuresis unrelated to drug therapy Hyperglycemia in the absence of diabetes Respiratory rate of seven breaths per minute Bradycardia with sudden increase in blood pressure

Hyperglycemia in the absence of diabetes

In assessing the vital signs of a patient with an upper gastrointestinal (GI) bleed, it is important to determine whether the patient is in which kind of shock? Septic Neurogenic Cardiogenic Hypovolemic

Hypovolemic

A patient is experiencing cardiogenic shock after an acute myocardial infarction. Why would an intraaortic balloon pump (IABP) be beneficial for this patient? Improves coronary artery vessel perfusion Reduces pressure in the pulmonary artery Enhances effectiveness of cardiac medications Provides time to perform an emergency angiogram

Improves coronary artery vessel perfusion

`What laboratory finding is consistent with a medical diagnosis of cardiogenic shock? Decreased liver enzymes Increased white blood cells Decreased red blood cells, hemoglobin, and hematocrit Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels

Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels (shows kidneys arent being perfused)

What laboratory finding correlates with a medical diagnosis of cardiogenic shock? Decreased liver enzymes Increased white blood cells Decreased red blood cells, hemoglobin, and hematocrit Increased blood urea nitrogen (BUN) and serum creatinine levels

Increased blood urea nitrogen (BUN) and serum creatinine levels

A nurse is caring for a patient in the intensive care unit (ICU) admitted with septic shock. The patient has been in the ICU for 36 hours. After 24 hours, which finding increases the patient's risk for developing multiple organ dysfunction syndrome (MODS)? Increased cardiac output Decreased coronary artery perfusion Increased systemic vascular resistance Decreased myocardial oxygen metabolism

Increased cardiac output

A pregnant patient is hospitalized with severe hemorrhage. The nurse expects what laboratory results? Select all that apply. Increased lactate levels Increased sodium levels Decreased hematocrit levels Decreased blood glucose levels Increased natriuretic peptide levels

Increased lactate levels Decreased hematocrit levels

When examining a patient in the progressive stage of shock, which factors related to the gastrointestinal (GI) system should the nurse consider? Select all that apply. Increased risk of GI bleeding Increased likelihood of GI ulcers Increased motility and peristalsis Increased ability to absorb nutrients Increased risk of bacterial migration from the GI tract to the bloodstream.

Increased risk of GI bleeding Increased likelihood of GI ulcers Increased risk of bacterial migration from the GI tract to the bloodstream.

A patient in septic shock is receiving fluid resuscitation. How will the nurse most accurately measure urine output? Daily weights Nasogastric tube Strict input and output Indwelling urinary catheter

Indwelling urinary catheter

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? Acute pain Impaired skin integrity Decreased cardiac output Ineffective tissue perfusion

Ineffective tissue perfusion

The health care provider prescribes 5% sodium chloride solution for the initial fluid replacement in a patient with hypovolemic shock. Which factors should the nurse consider when administering this solution to the patient? Select all that apply. Monitor the patient for bleeding. Protect the infusion from sunlight. Monitor the patient for renal failure. Infuse the solution through a central line. Monitor the patient closely for signs of hypernatremia.

Infuse the solution through a central line. Monitor the patient closely for signs of hypernatremia.

When caring for a patient in acute septic shock, what should the nurse anticipate? Infusing large amounts of IV fluids Administering osmotic and/or loop diuretics Administering IV diphenhydramine (Benadryl) Assisting with insertion of a ventricular assist device (VAD)

Infusing large amounts of IV fluids

When caring for a patient in acute septic shock, what should the nurse anticipate? Administering osmotic or loop diuretics Administering IV diphenhydramine (Benadryl) Infusing large amounts of intravenous (IV) fluids Assisting with insertion of a ventricular assist device (VAD)

Infusing large amounts of intravenous (IV) fluids

The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory-assist device should the nurse expect to use for this patient? Cardiopulmonary bypass Impedance cardiography (ICG) Intraaortic balloon pump (IABP) Central venous pressure (CVP) measurement

Intraaortic balloon pump (IABP)

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? Antibiotics are not useful when an infection has progressed to sepsis. Weaning the patient away from the ventilator is the top priority in sepsis. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.

Large amounts of IV fluid are required in sepsis to fill dilated blood vessels.

A nurse is monitoring the SvO 2 of a patient. The SvO 2 value is 50%. What does this value indicate? The cardiac output is normal. The patient is hypoventilating. Less oxygen is being delivered to the tissues. Less oxygen is being consumed by the tissues.

Less oxygen is being delivered to the tissues.

The nurse is caring for a patient with a pulmonary artery (PA) catheter. The nurse knows that this type of catheter is used to obtain what? Mixed atrial blood gas sampling Mixed arterial blood gas sampling Mixed venous blood gas sampling Mixed pulmonic vein blood gas sampling

Mixed venous blood gas sampling

A patient in shock is receiving 0.9 % NaCl (normal saline solution-NSS). Which nursing intervention is appropriate for this patient? Monitor the patient's vital signs Monitor for the signs of circulatory overload Monitor for signs of hypernatremia in the patient Monitor for allergic reactions and acute renal failure

Monitor for the signs of circulatory overload

A patient in neurogenic shock is receiving phenylephrine. Which nursing actions are appropriate when caring for this patient? Monitoring for signs of dyspnea and pulmonary edema Monitoring for signs of hypokalemia and hyperglycemia Monitoring for signs of reflex bradycardia and restlessness Monitoring for signs of hypothyroidism and Addison's disease

Monitoring for signs of reflex bradycardia and restlessness

The nurse is caring for a patient who developed cardiogenic shock. Which medical diagnosis does the nurse suspect? Urosepsis Hemorrhage Myocardial infarction Tension pneumothorax

Myocardial infarction

When choosing a vasopressor for a septic patient who is not responsive to fluid resuscitation, which drug would the nurse expect the healthcare provider to most likely order? Dopamine Vasopressin Hydrocortisone Norepinephrine

Norepinephrine

A patient's localized infection has become systemic and septic shock is suspected. What medication is expected to treat septic shock refractory to fluids? Insulin infusion Furosemide (Lasix) IV push Norepinephrine administered by titration Administration of nitrates and β-adrenergic blockers

Norepinephrine administered by titration

A pulmonary artery catheter has just been inserted through a patient's internal jugular vein. What is the nurse's priority action prior to infusing fluid? Obtain a chest x-ray Draw a hemoglobin level Evaluate electrolyte levels Obtain a 12-lead electrocardiogram

Obtain a chest x-ray

The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning? PaO 2 60 mm Hg Heart rate 96 beats/minute Blood pressure 100/56 mm Hg Urine output 260 mL in eight hours

PaO 2 60 mm Hg (should be 80-100)

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? Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL

PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding

A nurse is examining a patient with anaphylactic shock due to an insect bite. What types of skin manifestations would the nurse expect to find? Select all that apply. Pallor Pruritus Flushing Urticaria Cold, clammy skin

Pruritus Flushing Urticaria

The nurse is caring for a 34-yr-old woman with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment indicates the patient's condition is improving? Cardiac output (CO) is 3.5 L/min. Central venous pressure (CVP) is 10 mm Hg. Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. Systemic vascular resistance (SVR) is 1500 dynes/sec/cm-5.

Pulmonary artery wedge pressure (PAWP) is 10 mm Hg.

What is the clinical manifestation of systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) on the respiratory system? Pulmonary edema Pulmonary fibrosis Pulmonary embolism Pulmonary hypertension

Pulmonary hypertension

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? Obtain a 12-lead ECG and arterial blood gases. Rapidly administer 1000 mL normal saline solution IV. Administer norepinephrine (Levophed) by continuous IV infusion. Carefully insert a nasogastric tube and an indwelling bladder catheter.

Rapidly administer 1000 mL normal saline solution IV.

Which manifestation in a patient with systemic inflammatory response syndrome (SIRS) suggests respiratory system dysfunction? Refractory hypoxemia Pulmonary hypotension Increased lung compliance Decreased minute ventilation

Refractory hypoxemia

What occurs when the inflammatory response is activated in a patient with systemic inflammatory response syndrome (SIRS)? Release of mediators Decrease in metabolism Damage of the mesothelium Decrease in vascular permeability

Release of mediators

A nurse caring for a patient with sepsis completes an intravenous fluid infusion as ordered. Which is a goal for fluid resuscitation when caring for a patient diagnosed with sepsis? Restore tissue perfusion Increase circulating fluid volume Restore blood flow to the myocardium Achieve and maintain a mean arterial pressure of 50 mm Hg

Restore tissue perfusion

A nurse measures a patient's central venous pressure and recognizes a series of increased readings. What do these increased readings indicate to the nurse? Cardiogenic shock Circulatory failure Left ventricular failure Right ventricular failure

Right ventricular failure

A nurse is assessing a patient who is suspected of having hypovolemic shock. What are the conditions that can cause hypovolemic shock? Select all that apply. Ruptured spleen Valvular stenosis Bowel obstruction Diabetes insipidus Tension pneumothorax

Ruptured spleen Bowel obstruction Diabetes insipidus

A patient with a pulmonary arterial catheter for systolic heart failure is diagnosed with a urinary tract infection (UTI). The last central venous oxygen saturation (ScvO 2) mixed venous oxygen saturation (SvO 2) measurement was 89%. What should the nurse suspect is occurring with this patient? Sepsis Decreased cardiac output Increased oxygen demand Balanced oxygen supply and demand

Sepsis

The primary health care provider prescribes antibiotics and vasopressors for a patient. Which type of shock does the nurse expect to be treating? Septic shock Neurogenic shock Cardiogenic shock Anaphylactic shock

Septic shock

Which term is used to describe persistent hypotension despite adequate fluid resuscitation requiring vasopressors along with inadequate tissue perfusion resulting in tissue hypoxia? Sepsis Septic shock Inflammation Organ dysfunction

Septic shock

Vasopressor agents are prescribed for which types of shock? Select all that apply. Septic shock Neurogenic shock Obstructive shock Cardiogenic shock Hypovolemic shock

Septic shock Neurogenic shock

The nurse is caring for a patient who has hypovolemic shock. Which medical diagnosis does the nurse suspect? Insect bite Severe burns Myocardial infarction Pulmonary embolism

Severe burns

When managing a patient with shock, which appropriate actions should the nurse take as part of nutritional therapy? Select all that apply. Start enteral nutrition within the first 24 hours. Wait until the patient recovers to start with enteral nutrition. Start parenteral nutrition if enteral feedings are contraindicated. Start a slow continuous drip of small amounts of enteral feedings. Plan enteral feeding to meet at least 50 percent of calorie requirements.

Start enteral nutrition within the first 24 hours. Start parenteral nutrition if enteral feedings are contraindicated. Start a slow continuous drip of small amounts of enteral feedings.

A 64-yr-old male patient admitted to the critical care unit for gastrointestinal hemorrhage complains of feeling tense and nervous. He appears restless with increased blood pressure and pulse. If the physical assessment shows no other changes, it is most important for the critical care nurse to take which action? Administer prescribed IV dose of lorazepam (Ativan). Stay with the patient and encourage expression of concerns. Ask a family member to remain at the bedside with the patient. Teach the patient how to use guided imagery to reduce anxiety.

Stay with the patient and encourage expression of concerns.

A patient is diagnosed with heart failure. The nurse identifies that which factors may influence the patient's cardiac output? Select all that apply. Select all that apply Stroke volume Portal pressure Respiratory rate Myocardial contractility Decreased filling of the ventricles

Stroke volume Myocardial contractility Decreased filling of the ventricles

The nurse reviews the pathophysiology of heart failure. Which compensatory mechanism results in increased heart rate, increased myocardial contractility, and peripheral vasoconstriction? Ventricular dilation Ventricular hypertrophy Neurohormonal response Sympathetic nervous system (SNS) activation

Sympathetic nervous system (SNS) activation

The nurse is attempting to determine a patient's left ventricular afterload. Which hemodynamic value should the nurse use? Central venous pressure Pulmonary arterial pressure Systemic vascular resistance Peripheral vascular resistance

Systemic vascular resistance

The nurse recalls that symptoms of right-sided heart failure are caused by what condition? Decreased preload Increased cardiac output Fluid congestion in the lungs Systemic venous congestion

Systemic venous congestion

The nurse reviews the medical record of a patient with pneumonia and notes that the patient has hypotension, hypothermia, leukocytosis, and hypoxemia. What should the nurse infer from these findings? The patient has septic shock. The patient has neurogenic shock. The patient has cardiogenic shock. The patient has hypovolemic shock.

The patient has septic shock.

Which hematologic problem significantly increases the risks associated with pulmonary artery (PA) catheter insertion? Leukocytosis Hypovolemia Hemolytic anemia Thrombocytopenia

Thrombocytopenia (already a bleeding risk & this makes it higher risk)

The nurse reviews the assessment findings of a patient with acute decompensated heart failure (ADHF) and notes a pulmonary artery wedge pressure (PAWP) of 28 mm Hg, an intake of 1000 mL more than the output in 24 hours, and resistance to diuretics. The nurse anticipates a prescription for which clinical intervention? Oxygen therapy Ultrafiltration (UF) Biventricular pacing Cardiac transplantation

Ultrafiltration (UF)

Which are pathophysiologic effects of septic shock? Select all that apply. Vasodilation Myocardial depression Decreased coagulation Increased ejection fraction Maldistribution of blood flow Increased blood flow in the microcirculation

Vasodilation Myocardial depression Maldistribution of blood flow

The nurse is concerned about a patient's stroke volume. What determining factors should the nurse consider when determining stroke volume? a.Preload, afterload, and contractility b.Cardiac output, heart rate, and body surface area c.Afterload, cardiac output, and mean arterial pressure d.Cardiac index, mean arterial pressure, and blood pressure

a.Preload, afterload, and contractility