Prep U chapter 54
The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.
60 mm Hg Correct Explanation: Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients. The formula for calculating MAP is (2 × diastolic + systolic × 3)
Which of the following is a clinical manifestation of cardiac tamponade?
Narrowing pulse pressure Explanation: Signs and symptoms of cardiac tamponade include narrowing pulse pressure, chest pain, distant or muffled heart sounds, jugular vein distention, hypotension, and tachycardia.
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes
Head injury Correct Explanation: An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries. (less)
(see full question) You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?
In the compensation stage, catecholamines are released. Explanation: Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage.
Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:
Blood pressure. Explanation: By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.
Which of the following types of shock are older adults more likely to develop? Select all that apply
Cardiogenic shock • Hypovolemic shock Explanation: Older adults, particularly those with cardiac disease, are prone to cardiogenic shock. They are also more likely to develop hypovolemic shock because they have a decreased percentage of body water. Older adults are not prone to developing neurogenic, septic, or anaphylactic shock. (less)
The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by:
Cold, clammy skin and tachycardia. Explanation: In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident.
The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?
Compensatory stage Explanation: In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure
The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed
Narrowed pulse pressure Correct Explanation: Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP (Strehlow, 2010). Decreased or narrowing pulse pressure is an early indication of decreased stroke volume
Which of the following is a vasodilator that is used in the treatment of shock?
Nitroglycerin (Tridil) Explanation: Tridil is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Intropin and Dobutrex are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Levophed is a vasoconstrictor used to increase blood pressure by vasoconstriction.
Which of the following vasoactive medications may be used in the treatment of cardiogenic shock?
Norepinephrine (Levophed) • Milrinone (Primacor) • Amrinone (Inocor)
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?
Intubation and mechanical ventilation Correct Explanation: Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Periocardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate
Which stage of shock would encompass mechanical ventilation, altered level of consciousness, and profound acidosis?
Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, rapid, shallow respirations. There is not a stage of shock called the precompensatory stage. (less)
The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?
Lactated Ringer's Explanation: Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.
A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:
Oxygen at 2 L/min by nasal cannula Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.
Clinical characteristics of neurogenic shock are noted by which type of stimulation?
Parasympathetic The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The patient experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation. (
The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?
The patient has developed a stress ulcer that is bleeding. Explanation: GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus
What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?
Use strict hand hygiene techniques. Explanation: The incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques (Fried et al., 2011). Inserting an indwelling catheter would increase the risk of infection and thus of septic shock, not decrease it. Hand hygiene is more of a priority than administering prophylactic antibiotics. Masks would not prevent many types of infections
The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition?
You selected: 300 mL Correct Explanation: An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria.
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?
You selected: 5% albumin Correct Explanation: Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared to crystalloid solutions. Hetastarch and dextran solutions are not indicated for fluid administration because these agents interfere with platelet aggregation. Blood products are not indicated in this situation
You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?
You selected: A rapid, bounding pulse Correct Explanation: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible and pulse rhythm changes from regular to irregular. (less)
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next
You selected: Administers oxygen by nasal cannula at 2 liters per minute
You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client?
You selected: Adrenergic drugs Correct Explanation: Adrenergic drugs are the main medications used to treat shock.
A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is You selected: An older adult man with end-stage renal disease and an infected dialysis access site
You selected: An older adult man with end-stage renal disease and an infected dialysis access site Correct Explanation: MODS may develop when a client experiences septic shock. Those at increased risk for MODS are older clients, clients who are malnourished, and clients with coexisting disease.
A patient presents to the emergency department after being stung by a bee, complaining of difficulty breathing. What vasoconstrictive medication should be given at this time?
You selected: Epinephrine Correct Explanation: Anaphylactic shock is caused by a severe allergic reaction, such as to a bee sting, when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen- antibody reaction; specifically, an immunoglobulin E (IgE)- mediated response (see Chart 14-4). Intramuscular epinephrine is administered for its vasoconstrictive action. Diphenhydramine (Benadryl) is administered IV to reverse the effects of histamine, thereby reducing capillary permeability. Dexamethasone and prednisone are corticosteroids, which treat inflammation; they do not have vasoconstrictive properties, however. (less)
The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock?
You selected: It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Correct Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Respiratory distress syndrome can be a complication of shock but is not necessarily caused by shock. Shock does not begin when peripheral blood flow is inadequate. Not every trauma victim goes into shock
Which positioning strategy should be utilized for the patient diagnosed with hypovolemic shock?
You selected: Modified Trendelenburg Correct Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood.
When a patient is in the compensatory stage of shock which of the following symptoms occurs?
You selected: Tachycardia Correct Explanation: The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.
You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately?
You selected: The client's heart rate is greater than 90 beats per minute. Correct Explanation: A heart rate greater than 90 beats per minute or a respiratory rate greater than 20 breaths per minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output. (less)
As the nurse, you are clients' first line of defense in treating shock. When assessing a client for early signs of shock, what would you assess first?
You selected: Vital signs, skin color, and temperature
The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following
low
The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of
which shock? You selected: Septic Correct Explanation: In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress. (less)
Which is the most common type of shock?
You selected: Hypovolemic Correct Explanation: In hypovolemic shock, the most common type of shock, the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma.
The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. Appropriate interventions include
• obtaining a urine specimen for culture • administering pantoprazole (Protonix) IV daily • monitoring urine output every hour Explanation: The client is exhibiting signs of septic shock. It is important to identify the source of infection, such as obtaining a urine specimen for culture. Medication, such as pantoprazole, would be administered to prevent stress ulcers. The nurse would monitor urinary output every hour to evaluate effectiveness of therapy. IV sites would be changed and catheter tips cultured as this could be the source of infection. The client's condition warrants vital signs being assessed more frequently than every 4 hours. (less)
Which of the following colloids is expensive but rapidly expands plasma volume
albumin
A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order?
"Infuse I.V. fluids at 83 ml/hour." Explanation: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.
The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?
70% Correct Explanation: Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%
The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? Compensatory stage Explanation: In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure
Compensatory stage Explanation: In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?
Correct response: 5% albumin Explanation: Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared to crystalloid solutions. Hetastarch and dextran solutions are not indicated for fluid administration because these agents interfere with platelet aggregation. Blood products are not indicated in this situation
The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.
Correct response: 60 mm Hg Explanation: Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients. The formula for calculating MAP is (2 × diastolic + systolic × 3). (less)
The nurse is calculating a patient's mean arterial pressure (MAP). What is the patient's MAP, if the blood pressure is 110/70 mm Hg?
Correct response: 83 Explanation: Tissue perfusion and organ perfusion depend on mean arterial pressure (MAP), or the average pressure at which blood moves through the vasculature. MAP must exceed 65 mm Hg for cells to receive the oxygen and nutrients needed to metabolize energy in amounts sufficient to sustain life (Dellinger et al., 2013; Tuggle, 2010). True MAP can be calculated only by complex methods. An estimate of MAP may be calculated by using the following equation: MAP = DP + 1/3 (SP - DP). So, in this case, MAP = 70 + 1/3 (110-70) = 70 + 40/3 = 70 + 13.33 = 83.33, which rounds to 83. (less)
The nurse is caring for a client at risk for impending shock. The nurse is assessing the vital signs frequently. What systolic blood pressure (BP) value would indicate impending shock?
Correct response: 91 mm Hg Explanation: A systolic BP of 90 to 100 mm Hg indicates impending shock, whereas 80 mm Hg or below could indicate the presence of shock. The average systolic BP is 120 mm Hg for a normotensive adult
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers
Correct response: A continuous infusion of total parenteral nutrition Explanation: Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?
Correct response: Intubation and mechanical ventilation Explanation: Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Periocardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate. (less)
You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family?
Correct response: The client is not responding to medical interventions. Explanation: The irreversible stage occurs when significant cells and organs become damaged. The client's condition reaches a "point of no return" despite treatment efforts. The client no longer responds to medical interventions. Multiple systems begin to fail. When the kidneys, heart, lungs, liver, and brain cease to function, death is imminent.
How should vasoactive medications be administered?
Correct response: Using a central venous line Explanation: Vasoactive medications should be administered through a central venous line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV push.
A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to
Encourage the family to touch and talk to the client. Explanation: The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option. (less)
A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first
Lays the client flat with the feet elevated Explanation: The client may have fainted, which is a sign of transient neurogenic shock. To minimize pooling of blood in the legs and to restore blood flow to the brain, the nurse lays the client flat and elevates his or her feet. Another cause may be hypoglycemia. If the above action does not resolve the client's problem, the nurse should assess the client's blood glucose level. Raising the head of the bed would be done if the client had received spinal or epidural anesthesia. A bolus of IV fluids would be given if the client were dehydrated
A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse
Raises the foot of the client's bed Explanation: The description of the client is that of a person experiencing shock. In addition to administering fluids to a client in shock, the nurse positions the client with the legs elevated, which promotes venous blood return. Elevating the head of the bed will cause the client's blood pressure to drop even more. The Trendelenburg position will make breathing difficult and does not increase blood pressure or cardiac output. Placing the client in a side-lying position does not increase venous blood return
Morphine sulfate has which of the following effects on the body
Reduces preloa
A patient is being treated for septic shock. On assessment, the nurse notes an abnormal finding that is reported to the health care provider. Which of the following is most likely that finding?
SVO2 of 55% Correct Explanation: Normal SVO2 values range from 60% to 80%. Lower values indicate inadequate tissue perfusion and the need for medical intervention.
Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation?
Select all that apply. You selected: • Ranitidine (Zantac) • Lansoprazole (Prevacid) • Famotidine (Pepcid)
An 87-year-old client was admitted to your hospital unit with an elevated leukocyte count and a fever accompanied by warm, flushed skin. Which do her symptoms suggest?
She has an overwhelming bacterial infection. Explanation: Unlike other forms of shock, clients with septic shock have an elevated leukocyte count and initially manifest fever accompanied by warm, flushed skin and a rapid, bounding pulse. Therefore, the client with an overwhelming bacterial infection is most likely to exhibit these symptoms.
A nurse knows that the major clinical use of dobutamine (Dobutrex) is to:
increase cardiac output. Correct Explanation: Dobutamine increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure. (less)