Quiz 12: CH 37 - Care of Patients with Shock

The unlicensed assistive personnel (UAP) is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do?

Compare these vital signs with the last several readings.

Which laboratory result is seen in late sepsis?

Decreased segmented neutrophil count

How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)?

Mean arterial pressure (MAP) 70 mm Hg

Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective?

Serum lactate and the serum potassium levels are declining

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information:Physical Assessment FindingsDiagnostic FindingsPulse 140 beats/min and threadyABG respiratory acidosisBlood pressure 60/40 mm HgLactate level 63 mg/dL(7 mmol/L)Respirations 40/min and shallowAll of these provider prescriptions are given for the client. Which does the nurse carry out first?

Notify anesthesia for endotracheal intubation.

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock?

Tachycardia

What typical sign/symptom indicates the early stage of septic shock?

Tachypnea and tachycardia

A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis?

Temperature

Which nurse would be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection?

The RN with 2 years of experience in intensive care unit (ICU)

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? SATA

- Ask family members to stay with the client. - Remain with the client. - Reassure the client that everything is being done for him or her.

A client who is in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which ones does the nurse attribute to ongoing compensatory mechanisms? (Select all that apply.)

- Increasing pallor - Increasing thirst - Increasing heart rate - Increasing respiratory rate - Decreasing urine output

Which clients are at immediate risk for hypovolemic shock? SATA

- Unrestrained client in a motor vehicle collision (MVC) - Surgical intensive care unit (SICU) client - 85-year-old with gastrointestinal (GI) virus

A client with septic shock is to receive dopamine at 18 mcg/kg/min. The client's weight is 154 pounds. How many mcg/min does the nurse administer?__

1260 mcg/min (First convert pounds to kilograms: 154 lb ÷ 2.2 = 70 kg. Then, 70 kg × 18 mcg/kg/min = 1260 mcg/min.)

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome?

Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg

A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95°F (35°C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate?

Broad-spectrum antibiotics

When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first?

Check the airway and respiratory status.

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock?

Client with severe ascites

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first?

Ensure that blood cultures were drawn.

A client thought to be at risk for distributive shock is given a drug that constricts blood vessels. What effect does the nurse expect the drug to have on the client's mean arterial pressure (MAP)?

Increased MAP without a change in vascular volume.

The client with which laboratory result is at risk for hemorrhagic shock?

International normalized ratio (INR) 7.9

Which problem places a client at highest risk for sepsis?

Post kidney transplant

A 47-year-old obese woman with a history of type 2 diabetes and previous deep vein thrombosis of the right leg comes to the emergency department with an enlarged abdomen, nausea, a high blood glucose level of 278 mg/dL. She says she has felt tired for two days and has not eaten or taken any of her usual drugs (rivaroxaban [Xarelto] 20 mg, losartan [Cozaar] 50 mg, and metformin [Glucophage] 850 mg). Your initial assessment findings include pale skin and mucous membranes, abdominal tenderness, an irregular pulse of 118, an oral temperature of 96.4F (35.8C), a blood pressure of 102/40, and a pulse oximetry reading of 89%. Immediate orders are to draw blood for a complete blood count with differential, serum electrolytes, serum lactate; start an IV of D5% in 0.45% sodium chloride at 200 mL/hour, and apply oxygen by nasal cannula at 4L/min. 1. Which action should you perform first? Provide a rationale for your choice. 2. What signs or symptoms of shock are present? 3. What risk factors does this patient have for sepsis or for septic shock? 4. What other assessment data would be helpful in determining whether sepsis or septic shock is present? 5. How frequently should this patient be assessed? Provide a rationale for your answer.

1. First apply oxygen because the patient is hypoxic. The act of applying oxygen takes very little time. Being hypoxic only makes any type of shock situation worse by increasing anaerobic metabolism. Then start the IV, often the blood for laboratory specimens can be taken while obtaining IV access. 2. The increased heart rate, paleness, low diastolic blood pressure, and low oxygen saturation are all symptomatic of any type of shock. The elevated blood glucose level and the low body temperature are indications of possible sepsis or septic shock. 3. The patient has diabetes, which increases the risk for infection, the ultimate cause of sepsis and septic shock. The fact that she is obese is not a direct risk factor; however, obesity often impairs circulation to lower extremities and increases the risk for a deep vein thrombosis, which she has already had. This should be considered a general risk for inappropriate clotting. She is taking rivaroxaban, which indicates her health care provider considers her at continuing risk for clotting. 4. Obtaining specimens of urine, blood, sputum, and any drainage for culture to identify the causative organisms could be helpful for determining sepsis; however, the results of these cultures will take too long to be immediately helpful. Arterial blood gases to determine pH and a serum procalcitonin level would provide more immediate supporting data for a sepsis diagnosis. In addition, an activated protein C level that is below normal can indicate severe sepsis even before other symptoms are evident. Insertion of a Foley catheter for urine output monitoring would also be helpful. Electrocardiographic (ECG) assessment is indicated by the irregular heart rate (which can be worsened by hypoxemia). 5. This patient is very ill as indicated by the hypoxemia without a history of respiratory problems. Her condition could change quickly and even small or subtle changes need to be noticed. Therefore, she should be continuously monitored by a registered nurse. The above case study is taken from an actual patient situation. The diagnosis of septic shock was made within 30 minutes of admission to the emergency department and appropriate antibiotic and other supportive therapies were initiated at that time. Despite all interventions, the patient died about 3 hours after initially being seen. At autopsy, she was found to have a necrotic bowel as a result of clots in her mesenteric artery. Bowel contents had been leaking for some time (days) into her peritoneum, causing the sepsis and septic shock.

The client in shock has the following vital signs: T 99.8°F, P 132 beats/min, R 32 breaths/min, and BP 80/58 mm Hg. Calculate the pulse pressure.__

22 mm Hg

Which problem places a person at highest risk for septic shock?

40% burn injury

With which client should the nurse remain alert for the possibility of sepsis and septic shock?

67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago.

A client with hypovolemic shock has these vital signs: temperature 97.9°F (36.6°C); pulse 122 beats/min; blood pressure 86/48 mm Hg; respirations 24 breaths/min; urine output 20 mL for last 2 hours; skin cool and clammy. Which prescription order for this client does the nurse question?

Bumetanide (Bumex) 1 mg IV

The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider?

Discussion with family and provider regarding palliative care

The client with which problem is at highest risk for hypovolemic shock?

Esophageal varices

How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present?

Lactate 81 mg/dL (9.0 mmol/L)

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated?

Low-grade fever and mild hypotension

A postoperative client is admitted to the intensive care unit (ICU) with hypovolemic shock. Which nursing action does the nurse delegate to an experienced unlicensed assistive personnel (UAP)?

Measure hourly urine output.