Shock test review
. When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock
d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock Rationale: Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.
b. Monitor breath sounds frequently. rationale: Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.
1. A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/minute. The label on the infusion bag states: dobutamine 250 mg in 250 mL normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many mL per hour?
27 In order to administer the dobutamine at the prescribed rate of 5 mcg/kg/minute from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hour.
7. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% human albumin b. Furosemide (Lasix) IV c. Epinephrine (Adrenalin) drip d. Hydrocortisone (Solu-Cortef)
b. Furosemide (Lasix) IV Rationale: The PAWP indicates that the patients preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.
4. An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? a. Increase the rate for the dopamine (Intropin) infusion. b. Decrease the rate for the nitroglycerin (Tridil) infusion. c. Increase the rate for the sodium nitroprusside (Nipride) infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5 /.9 NS) infusion.
c. Increase the rate for the sodium nitroprusside (Nipride) infusion. Rationale: Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5 /.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.
3. Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation
d. Oxygen saturation rationale: Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.
1. The health care provider orders the following interventions for a 67-kg patient who has septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90% on room air. In which order will the nurse implement the actions?(Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Start norepinephrine (Levophed) 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.
e. Titrate oxygen administration to keep O2 saturation >95%. d. Infuse normal saline 2000 mL over 30 minutes. c. Start norepinephrine (Levophed) 0.5 mcg/min. a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. Rationale: The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.
Which clinical finding would the nurse expect to find in a patient with SIRS with hepatic impairment? A. Hypoxia B. Bruising C. Paralytic ileus D. Decreased glomerular filtration rate (GFR)
B. Bruising Rationale: Clotting factors are formed in the liver. Hepatic impairment from SIRS interferes with the formation of clotting factors. Therefore, the nurse would expect to find bruising.
A patient with a massive gastrointestinal bleed has developed hypovolemic shock. What is the priority nursing diagnosis? A. Anxiety B. Acute pain C. Impaired tissue integrity D. Ineffective tissue perfusion
D. Ineffective tissue perfusion Rationale: The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.
Which types of shock are associated with decreased cerebral perfusion? Select all that apply. A. Septic shock B. Neurogenic shock C. Obstructive shock D. Cardiogenic shock E. Anaphylactic shock F. Hypovolemic shock
C. Obstructive shock, D. Cardiogenic shock, F. Hypovolemic shock rationale: Decreased cerebral perfusion associated with obstructive shock causes anxiety, confusion, and agitation. Manifestations of cardiogenic shock include decreased cerebral perfusion that causes anxiety, confusion, and agitation. Decreased cerebral perfusion associated with hypovolemic shock causes anxiety, confusion, and agitation. Septic shock causes mental changes like confusion, agitation, and coma in the late stages. Loss of reflex activity and flaccid paralysis are seen with neurogenic shock. Anxiety, feeling of impending doom, confusion, decreased level of consciousness, and metallic taste are signs of anaphylactic shock. Test-taking tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation
Which sign would the nurse monitor for in a patient with neurogenic shock receiving phenylephrine? A. Dyspnea B. Hypokalemia C. Reflex bradycardia D. Hypothyroidism
C. Reflex bradycardia Rationale: Phenylephrine is a B- adrenergic agonist and may cause bradycardia and restlessness due to central nervous system stimulation. B- adrenergic agonists such as epinephrine cause dyspnea and pulmonary edema. Phenylephrine does not increase the elimination of potassium levels or blood glucose levels. Therefore the patient does not have a risk of hypokalemia and hyperglycemia. Phenylephrine does not impair thyroid and adrenal gland functioning. Therefore the nurse will not monitor for the signs of hypothyroidism and Addison's disease. Test-taking tip: Identify option components as correct or incorrect. This may help you to identify a wrong answer.
which condition does a patient with cardiogenic shock typically experience? A. Hypotension B. Dysrhythmias C. Volume excess D. Volume depletion
C. Volume excess Rationale: In cardiogenic shock, the heart fails as a pump. This usually results in fluid retention and poor perfusion of organs, including the kidneys, which adds to the fluid volume excess. As cardiogenic shock progresses, hypotension will develop, but it is not the cause of cardiogenic shock. Dysrhythmias may or may not be present with cardiogenic shock. Volume depletion is not generally seen with cardiogenic shock. It is, however, seen more hypovolemic or distributive forms of shock.
After coronary artery bypass graft surgery, a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care? A. Cardiac index (CI) of 5 L/min/m2 B. Central venous pressure of 8 mm Hg C. Mean arterial pressure (MAP) of 86 mm Hg D. Pulmonary artery pressure (PAP) of 28/14 mm Hg
D. Pulmonary artery pressure (PAP) of 28/14 mm Hg Rationale: Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be a result of the MI. The CI, CVP, and MAP readings are normal.
1. A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? a. Give PRN furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Administer hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
a. Give PRN furosemide (Lasix) 40 mg IV. Rationale: Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.
. A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.
a. Give normal saline IV at 500 mL/hr. rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.
After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg
b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics rationale: Antibiotics should be administered within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS) and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.
6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Palpate for abdominal pain. c. Ask the patient about nausea. d. Check stools for occult blood
d. Check stools for occult blood rationale: Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration.
The nurse assesses a patient with cardiogenic shock and expects which findings? select all that apply. A. Anxiety B. Tachycardia C. Hypertension D. Decreased urine output E. Weak peripheral pulses
A. Anxiety, B. Tachycardia, D. Decreased urine output, E. Weak peripheral pulses Rationale: The early presentation of a patient with cardiogenic shock is similar to that of a patient with acute decompensated heart failure (HF). The patient may have tachycardia. signs of peripheral hypoperfusion (e.g cyanosis, pallor, diaphoresis, weak peripheral pulses, cool and clammy skin, delayed capillary refill) occur. decreased renal blood flow results in sodium and water retention and decreased urine output. Anxiety, confusion, and agitation may develop with impaired cerebral perfusion. The patient may have hypotension, not hypertension
Which medication would the nurse prepare to administer to a patient with septic shock? A. insulin infusion B. Aggressive IV crystalloid fluid resuscitation C. IV administration of epinephrine D. Administration of nitrates and B- adrenergic blockers
B. Aggressive IV crystalloid fluid resuscitation Rationale: Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and B- adrenergic blockers are used most often in the treatment of patients in cardiogenic shock.
The nurse would recognize which assessment finding as suggestive of sepsis? A. Sudden diuresis unrelated to drug therapy B. Hyperglycemia in the absence of diabetes C. Respiratory rate of seven breaths per minute D. Bradycardia with sudden increase in blood pressure
B. Hyperglycemia in the absence of diabetes Rationale: Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.
9. Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm
B. Urine output is 60 mL over the last hour Rationale: Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.
2. A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg. d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg
a. Infuse normal saline at 250 mL/hr. Rationale: The patients elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the patient.
During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Heart rate 112 beats/minute c. Decreased bowel sounds d. Pale, cool, and dry extremities
a. New onset of confusion rationale: The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.
3. A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles. b. Cool, clammy extremities. c. Apical heart rate 45 beats/min. d. Temperature 101.2 F (38.4 C).
c. Apical heart rate 45 beats/min. Rationale: Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Initiate continuous electrocardiogram (ECG) monitoring. c. Provide oxygen at 100% per non-rebreather mask. d. Draw blood to type and crossmatch for transfusions.
c. Provide oxygen at 100% per non-rebreather mask. rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize oxygen delivery have been implemented.
Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? a. The patients urine output is 18 mL/hr. b. The patients heart rate is 110 beats/minute. c. The patient is complaining of chest pain. d. The patients peripheral pulses are weak.
c. The patient is complaining of chest pain. rationale: Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patients diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy.
Match the type of shock with its cause. 1.Loss of intravascular fluid 2.Systolic or diastolic dysfunction 3.Massive vasodilation without compensation 4.Acute allergic reaction to a sensitizing substance A. anaphylactic shock B. Cardiogenic shock C. neurogenic shock D. Hypovolemic shock
1.Loss of intravascular fluid D. Hypovolemic shock 2.Systolic or diastolic dysfunction B. Cardiogenic shock 3.Massive vasodilation without compensation C. Neurogenic shock 4.Acute allergic reaction to a sensitizing substance A. Anaphylactic shock
The nurse is caring for a patient with septic shock due to a urinary tract infection. The patient has developed microthrombi in the extremities. What are the underlying causes for this manifestation? select all A. Cytokines B. Interleukins C. Decreased oxygenation D. Diminished tissue perfusion E. Impaired cellular metabolism
A. Cytokines, B. Interleukins Rationales: Cytokines The proinflammatory cytokine release causes microthrombi formation in the extremities. Interleukins The proinflammatory response of interleukins leads to microthrombi formation in the extremities.
The nurse enters the room of a patient admitted with Systemic Inflammatory Response Syndrome (SIRS). What would the nurse expect to find on assessment? select all A. Hypoxemia B. Tachycardia C. Hypertension D. Decreased urinary output E. Hyperactive bowel sounds
A. Hypoxemia, B. Tachycardia, D. Decreased urinary output Rationale: Hypoxemia A patient with SIRS will be hypoxic due to low oxygen levels. Tachycardia The nurse would expect a patient with SIRS to have tachycardia. Decreased urinary output SIRS can affect renal function, which would lead to decreased urinary output.
A patient is admitted to the hospital with septic shock and multiple organ dysfunction syndrome (MODS). Which organ systems would the nurse expect to be affected first? select all A. Renal B. Endocrine C. Respiratory D. Integumentary E. Cardiovascular
A. Renal, C. Respiratory, E. Cardiovascular rationale: Renal The renal system is one of the first systems to be affected in MODS. Respiratory One of the first systems affected in MODS is the respiratory system. Cardiovascular The cardiovascular system is initially affected in patients with MODS.
Which conditions can cause hypovolemic shock? select all that apply. A. Ruptured spleen B. Valvular stenosis C. Bowel obstruction D. Diabetes insipidus E. Tension pneumothorax
A. Ruptured spleen, C. Bowel obstruction D. Diabetes insipidus Rationale: Hypovolemic shock may be caused due to bowel obstruction, a ruptured spleen, or diabetes insipidus. Bowel obstruction causes relative hypovolemia by preventing fluid absorption for the bowel. A ruptured spleen may cause massive internal bleeding, leading to hypovolemia. Diabetes insipidus causes a marked increase in fluid loss through the kidneys, leading to hypovolemia. A tension pneumothorax and valvular stenosis may lead to cardiogenic shock.
Which conditions could be the possible cause of obstructive shock? Select all that apply. A. Spinal cord injury B. Cardiac tamponade C. Tension pneumothorax D. Hypersensitivity to antibiotics E. Superior vena cava syndrome
B. Cardiac tamponade, C. Tension pneumothorax E. Superior vena cava syndrome Rationale: Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression caused by cardiac tamponade, tension pneumothorax, or superior vena cava syndrome. Spinal cord injury may lead to neurogenic shock. Hypersensitivity to antibiotics may cause anaphylactic shock
A nurse is examining a patient with anaphylactic shock. Which types of skin manifestations would the nurse expect to find? Select all that apply. A. Pallor B. Pruritus C. Flushing D. Urticaria E. Cold Skin
B. Pruritus , C. Flushing , D. Urticaria Rationale: Insect bites may cause allergic reactions and anaphylactic shock. The skin manifestations may include pruritus, flushing , and urticaria caused by massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. Pallor and cold, clammy skin changes are usually seen in cardiogenic, hypovolemic, and obstructive shock caused by decreased circulatory volume and tissue perfusion.
Which type of shock is associated with hyperglycemia, the presence of pulmonary infiltrates in a chest x-ray, and increased levels of blood urea nitrogen (BUN)? A. Septic B. Obstructive C. Cardiogenic D. Hypovolemic
C. Cardiogenic Rationale: Increased blood levels of glucose, nitrogen, and cardiac markers, and the presence of pulmonary infiltrates are seen in cardiogenic shock. increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock. Test-taking tip: identify option components are correct or incorrect. This may help you to identify a wrong answer.
Which type of shock causes an absence of bowel sounds? A. neurogenic B. Cardiogenic C. Hypovolemic D. Anaphylactic
C. Hypovolemic Rationale: Absence of bowel sounds is associated with hypovolemic shock. Decreased bowel sounds are seen with cardiogenic shock. Bowel dysfunction is associated with neurogenic shock. Abdominal pain, nausea, and vomiting are seen with anaphylactic shock. Testing taking tip: Identifying content and what is being asked about the content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options
A patient presents with a broken femur after a motor vehicle accident. Which assessment findings should the nurse expect if the patient was developing shock? A. Dry skin, low blood pressure, diarrhea B. Erythema, low blood pressure, increased urinary output C. Low blood pressure, prolonged capillary refill, tachycardia D. Decreased pulse, normal blood pressure, normal respirations
C. Low blood pressure, prolonged capillary refill, tachycardia rationale: A patient who is developing shock from a motor vehicle accident will present with low blood pressure, prolonged capillary refill, and tachycardia due to blood loss and overexertion of the heart.
Which fluid increases osmotic pressure to provide rapid volume expansion for a patient experiencing hypovolemic shock? A. Lactated Ringer's B. 3% sodium chloride C. Fresh frozen plasma D. Human serum albumin
D. Human serum albumin Rationale: Human serum albumin is a colloidal fluid that increases osmotic pressure and will provide rapid volume expansion. Lactated Ringer's and 3% sodium chloride are used for initial volume replacement in shock, but they do not provide rapid volume expansion. Fresh frozen plasma is used to replace blood loss and replace coagulation factors.
A patient with multiple bee stings has edema on the lips and tongue, chest pain, dizziness, wheezing, and stridor. Which type of shock would the nurse expect to incorporate into the plan of care? A. Septic B. Obstructive C. Neurogenic D. Anaphylactic
D. Anaphylactic Rationale: Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is inset venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Obstructive shock develops when a physical obstruction to blood flow occurs with decreased cardiac output. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above.
Which laboratory finding is consistent with cardiogenic shock? A. Decreased liver enzymes B. Increased white blood cells C. Decreased red blood cells, hemoglobin, and hematocrit D. Increased blood urea nitrogen (BUN) and creatinine levels
D. Increased blood urea nitrogen (BUN) and creatinine levels Rationale: The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, but white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia
The nurse is caring for a patient in cardiogenic shock after an acute myocardial infarction. Which assessment findings would be most concerning? A. Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds B. Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL C. Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin D. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding
D. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding Rationale: Severe hypoxemia, lactic acidosis, and bleeding are manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold and clammy skin, agitation, tachypnea, and increased serum creatinine are manifestations of the progressive stage of shock.
Which arterial blood gas finding is associated with a patient experiencing early shock? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
D. Respiratory alkalosis Rationale: Respiratory alkalosis is associated with early signs of shock as a result of hyperventilation. Metabolic acidosis and alkalosis, or respiratory acidosis, are not arterial blood gas findings related to early shock. Test-taking tip: sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question
11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patients central venous pressure is 3 mm Hg. b. The patient is in sinus tachycardia at 120 beats/min. c. The patient is receiving low dose dopamine (Intropin). d. The patient has had no urine output since being admitted.
a. The patients central venous pressure is 3 mm Hg. Rationale: Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patients low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
14. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patients serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patients extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.
a. The patients serum creatinine level is elevated. rationale: The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patients diagnosis of cardiogenic shock.
18. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. obtain a 12-lead electrocardiogram (ECG). c. obtain the blood pressure. d. check the level of consciousness.
a. administer oxygen. rationale: The initial actions of the nurse are focused on the ABCs airway, breathing, and circulation and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.
12. A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure 92/40 mm Hg
c. Warm, pink, and dry skin rationale: Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.
Which drug causes arterial and venous dilation? A. Dopamine B. Vasopressin C. Phenylephrine D. Sodium nitroprusside
D. Sodium nitroprusside Rationale: Sodium nitroprusside acts by dilating both the arteries and veins. It is used in the treatment of cardiogenic shock. Dopamine has inotropic activity. It increases the force of the heartbeat and is used in the treatment of cardiogenic shock. Vasopressin is a vasoconstrictor used mainly in the treatment of septic shock. Phenylephrine acts by constricting the peripheral nerves and is used in the treatment of neurogenic shock. Test-Taking tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.
Which intervention would the nurse incorporate into the plan of care for a patient in hypovolemic shock who is becoming anxious and whose urine is decreasing? A. Being crystalloid fluid replacement B. Start fluids only if deterioration occurs. C. Prepare for administering blood products D. Wait for the patient to compensate naturally.
A. Begin crystalloid fluid replacement Rationale: When the volume of blood loss is less than 30%, crystalloid fluid replacements are performed to reverse tissue dysfunction. Blood products are administered when the blood volume loss is more than 30%. The nurse should not wait for deterioration to occur to start fluid replacement therapy. This is because the body can typically compensate naturally for a blood volume loss up to 15% Test-Taking tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, then it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.
Vasopressor agents are prescribed for which types of shock? Select all that apply A. Septic B. Neurogenic C. Obstructive D. Cardiogenic E. Hypovolemic
A. Septic, B. Neurogenic Rationale: Septic shock occurs in response to an infection. It is associated with the release of cytokines and other inflammatory mediators, resulting in vasodilation, increased capillary permeability, and platelet aggregation. Vasopressors will constrict the blood vessels and relieve hypotension. Neurogenic shock is caused by a severe injury to the cnetral nervpus system (CNS), causing a loss of sympathetic stimulations of blood vessels resulting in vasodilatation. A fall in BP can be restored by administering vasopressor agents that act by constricting the blood vessels. Obstructive shock is caused by and an obstruction in the vessels of the heart or the heart itself. Restoring the circulation by treating the cause of obstruction will be beneficial for a patient with obstructive shock. systolic or diastolic dysfunction of the heart results in cardiogenic shock. Treatment involves use of nitrates, inotropes, diuretics and B-blockers. A loss in the intravascular fluid volume causes hypovolemic shock. Treatment of hypovolemic shock includes restoring the fluid volume by infusion of blood or blood products and crystalloids. Test- taking tip: Identify option components as correct or incorrect. This may may help you identify a wrong answer
The nurse assesses a patient and suspects a diagnosis of neurogenic shock based on which findings? select all that apply A. Dyspnea B. Bradycardia C. Weak pulses D. Hypotension E. Unstable temperature
B. Bradycardia, D. Hypotension, E. Unstable temperature Rationale: Signs of neurogenic shock include bradycardia, hypotension, and temperature instability. Dyspnea and weak pulses are not signs associated with neurogenic shock.
A patient admitted with an acute myocardial infarction from severe coronary artery disease is at risk for developing which type of shock? A. Neurogenic Shock B. Cardiogenic Shock C. Anaphylactic Shock D. Hypovolemic Shock
B. Cardiogenic Shock Rationale: A patient that sustained an acute myocardial infarction is at risk for developing cardiogenic shock.
Which type of shock can be treated by minimizing spinal cord trauma with stabilization A. Septic shock B. Neurogenic shock C. Anaphylactic shock D. Hypovolemic shock
B. Neurogenic shock Rationale: Neurogenic shock is caused by severe injury to the spinal cord and results in loss of sympathetic stimulation of blood vessels. Apart from administering vasoconstrictor agents, minimizing the spinal cord trauma with stabilization is a supporting therapy for neurogenic shock. Septic shock occurs in response to a systemic infection. Obtaining the cultures before starting antibiotics is appropriate care for septic shock. A life- threatening allergic reaction to a sensitizing substance causes anaphylactic shock. Avoiding exposure to allergens is supportive therapy for anaphylactic shock. Excessive loss of intravascular fluid causes hypovolemic shock. Besides restoring fluid volume, correcting the cause of fluid loss is supportive therapy. test- taking tip: If the question asks for an immediate action or response, then all the answers may be correct, so base your selection on identified priorities for action.
The nurse is caring for a patient who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The provider states the patient has developed sepsis, and the family members have many questions. Which information should the nurse include when explaining the early stage of sepsis? A. Weaning the patient from the ventilator is the top priority in sepsis. B. Antibiotics are not useful when an infection has progressed to sepsis. C. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. D. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.
C. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. Rationale: Patients with sepsis may be normovolemic, but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Additional respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.
17. The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute
b. Skin cool and clammy rationale: Because patients in the early stage of septic shock have warm and dry skin, the patients cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patients status.
The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Start a normal saline infusion. b. Give epinephrine (Adrenalin). C. Start continuous ECG monitoring. d. Give diphenhydramine (Benadryl).
b. Give epinephrine (Adrenalin). rationale: Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.
A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringers solution. d. Provide high-flow oxygen (100%) by non-rebreather mask. e. Prepare for emergent intubation and mechanical ventilation
a. Prepare to administer atropine IV. b. Obtain baseline body temperature. d. Provide high-flow oxygen (100%) by non-rebreather mask. e. Prepare for emergent intubation and mechanical ventilation Rationale: All of the actions are appropriate except to give large volumes of lactated Ringers solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringers solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.
5. After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. nitroglycerine (Tridil). b. norepinephrine (Levophed). c. sodium nitroprusside (Nipride). d. methylprednisolone (Solu-Medrol).
b. norepinephrine (Levophed). Rationale: When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside is an arterial vasodilator and would further decrease SVR.
Which nursing interventions would the nurse perform when administering dopamine to a patient experiencing cardiogenic shock? select all that apply. A. Administer via a central line B. Monitor for tachydysrhythmias C. Administer with sodium bicarbonate. D. Monitor for peripheral vasoconstriction E. Monitor for pulmonary edema
A. Administer via a central line, B. Monitor for tachydysrhythmias, D. Monitor for peripheral vasoconstriction Rationale: Dopamine is positive inotropic agent used in cardiogenic shock. The drug may cause tissue sloughing, if infiltrated. Therefore it is administered through a central line and not via a peripheral line. The patient should be monitored for tachydysrhythmias caused by enhanced inotropic effects. There is also a risk for peripheral vasoconstriction, so the nurse should be observant for symptoms such as paresthesia and coldness of the extremities. The drug may get deactivated by an alkaline solution; therefore it should not be administered along with sodium bicarbonate. Because dopamine is not known to have an adrenergic action, it will not cause pulmonary edema
Which laboratory levels would the nurse expect when caring for a patient with sever hemorrhage? Select all that apply A. Increased lactate B. Increased sodium C. Decreased hematocrit D. Decreased blood glucose E. Increased natriuretic peptide
A. Increased lactate, C. Decreased hematocrit Rationale: Sever hemorrhage results in blood loss and hypovolemic shock in the patient. due to the loss of blood, the patient has increased lactate levels and decreased hematocrit levels. loss of blood does not results in sodium retention and does not increase serum sodium levels. Loss of blood will not increase insulin levels and does not decrease blood glucose levels in the patient. Hypovolemia will not stimulate cardiac myocytes and will not increase the production of natriuretic peptide levels. Therefore the patient will probably not have increased sodium levels, decreased blood glucose levels, or increased natriuretic peptide levels Test-Taking tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation
When caring for a patient in acute septic shock, what should the nurse anticipate? A. Infusing large amounts of IV fluids B. Administering osmotic and/or loop diuretics C. Administering IV diphenhydramine (Benadryl) D. Assisting with insertion of a ventricular assist device (VAD)
A. Infusing large amounts of IV fluids Rationale: Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. Administering diuretics is inappropriate. VADs are useful for cardiogenic shock, not septic shock. Diphenhydramine may be used for anaphylactic shock but would not be helpful with septic shock.
The nurse anticipates which clinical findings in a patient who presents with anaphylactic shock? select all that apply A. Stridor B. Pruritus C. Anxiety D. Pallor E. Chest pain
A. Stridor, B. Pruritus, C. Anxiety, E. Chest pain Rationale: Clinical findings associated with anaphylactic shock include stridor, pruritus, anxiety, and chest pain. The patient will experience skin flushing, not pallor.
The nurse is caring for a patient with cardiogenic shock. Which information obtained by the nurse would suggest the patient is developing multiple organ dysfunction syndrome (MODS)? A. The patient's serum creatinine level is elevated. B. The patient complains of intermittent chest pressure. C. The patient has wheezes throughout both lung fields. D. The patient's extremities are cool and pulses are weak.
A. The patient's serum creatinine level is elevated. rationale: A patient who may be developing MODS will present with renal impairment. This is manifested by an elevated serum creatinine.
When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which manifestation of multiple organ dysfunction syndrome (MODS)? A. Increased serum albumin B. Decreased respiratory compliance C. Increased gastrointestinal (GI) motility D. Decreased blood urea nitrogen (BUN)/creatinine ratio
B. Decreased respiratory compliance Rationale: Manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.
The nurse is caring for a patient postoperatively for removal of a sponge from a previous hysterectomy. The patient is receiving broad-spectrum antibiotics. What results on assessment would lead the nurse to be concerned that the patient is developing Systemic Inflammatory Response Syndrome (SIRS)? A. Increased HR, increased RR, and increased BP B. Increased HR, increased RR, and decreased BP C. Decreased HR, increased RR, and decreased BP D. Increased HR, increased RR, and in a hypertensive crisis
B. Increased HR, increased RR, and decreased BP Rationale: A patient who is developing SIRS may develop an increased HR, RR, and a decreased BP. These symptoms occur due to vasodilation and hypoxia.
Which type of shock is associated with bradycardia A. Septic B. Neurogenic C. Anaphylactic D. Hypovolemic
B. Neurogenic Rationale: Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. chest pain is seen in anaphylactic shock. Reduction in preload, capillary refill, and stroke volume are clinical manifestations of hypovolemic shock. Test-taking tip: make certain that the answer you select is reasonable and obtainable under circumstances and that the action can be carried out in the given situation
A patient is admitted to the emergency department vomiting bright red blood. The patient's vital signs are BP 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 provider order should the nurse complete first? A. Obtain a 12-lead ECG and arterial blood gases. B. Rapidly administer 1000 mL normal saline solution IV. C. Start norepinephrine (Levophed) by continuous IV infusion. D. Insert a nasogastric tube and an indwelling bladder catheter.
B. Rapidly administer 1000 mL normal saline solution IV. Rationale: Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be done after fluid resuscitation is started.
A patient with a suspected brain tumor is scheduled for a CT scan with contrast media. The nurse notifies the provider that the patient reported an allergy to shellfish. Which response by the provider should the nurse question? A. Complete the CT scan without contrast media. B. Give IV diphenhydramine before the procedure. C. Give IV lorazepam (Ativan) before the procedure. D. Premedicate with hydrocortisone sodium succinate.
C. Give IV lorazepam (Ativan) before the procedure. Rationale: A person with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.
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. A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture B. A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia C. A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina D. A 82-yr-old patient with type 2 diabetes and chronic kidney disease admitted for peritonitis from a peritoneal dialysis catheter infection
D. A 82-yr-old patient with type 2 diabetes and chronic kidney disease admitted for peritonitis from a peritoneal dialysis catheter infection Rationale: A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Those at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.
Which conditions would put a patient at risk for hypovolemic shock? select all A. Spinal cord injury B. Myocardial infarction C. Urinary tract infection D. Excessive hemorrhaging E. Prolonged vomiting and diarrhea
D. Excessive hemorrhaging, E. Prolonged vomiting and diarrhea Rationale: Excessive hemorrhaging A patient who is losing large amounts of blood will be at risk for hypovolemic shock. Prolonged vomiting and diarrhea A patient with large volumes of fluid loss from prolonged nausea, vomiting, and diarrhea will be at risk for hypovolemic shock.
. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patients heart rate is 58 beats/minute. b. The patients extremities are warm and dry. c. The patients IV infusion site is cool and pale. d. The patients urine output is 28 mL over the last hour.
c. The patients IV infusion site is cool and pale. rationale: The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.
8. The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain a. hypothermia blanket. b. lactated Ringers solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.
c. two 14-gauge IV catheters. rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringers solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.
When managing a patient with shock, which actions would the nurse take as part of nutritional therapy? select all that apply. A. Start enteral nutrition within the first 24 hours. B. Wait until the patient recovers to start with enteral nutrition C. Start parenteral nutrition if enteral feedings are contraindicated. D. Start a slow continuous drip of small amounts of enteral feedings E. Plan enteral feeding to meet at least 50% of calorie requirements
A. Start enteral nutrition within the first 24 hours, C. Start parenteral nutrition if enteral feedings are contraindicated D. Start a slow continuous drip of small amounts of enteral feedings Rationale: Enteral nutrition should ideally begin within the first 24 hours. It is important because it enhances the perfusion of the gastrointestinal (GI) tract and helps to maintain the integrity of the gastrointestinal mucosa. Enteral feeding should be started with a slow, continuous drip of small amounts of enteral feedings. If enteral feedings are contraindicated, then parenteral feedings can be started. Nutritional therapy should start as early as possible. The nurse should not wait for the patient to recover before starting nutritional therapy. Enteral feeding should be planned to meet at least 80% of the total calorie requirements, but if it is not feasible, parenteral feeding should be started.
When caring for a patient in acute septic shock, which intervention would the nurse expect to incorporate into the plan of care? A. Administering osmotic or loop diuretics B. Administering IV diphenhydramine C. Infusing large amounts of IV fluids D. Assisting with insertion of a ventricular assist device (VAD)
C. Infusing large amounts of IV fluids Rationale: Septic shock is characterized by decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. Diphenhydramine may be used for anaphylactic shock but would not be helpful with septic shock. VADs are useful for cardiogenic shock, not septic shock. Test-taking tip: answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation. Test-Taking tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation
The nurse knows that a patient with which condition is at risk for SIRS? A. Type 2 diabetes B. Severe alcoholism C. Myocardial infarction D. Untreated hypertension
C. Myocardial infarction rationale: A patient who sustained a myocardial infarction is at risk for developing SIRS due to myocardial ischemia.
Which medical diagnosis would the nurse suspect as the cause of cardiogenic shock? A. Urosepsis B. Hemorrhage C. Myocardial infarction D. Tension pneumothorax
C. Myocardial infarction Rationale: Myocardial infarction may produce necrotic areas of cardiac tissue that lead to impaired contractility and decreased cardiac output. This may lead to a cardiogenic shock state. Hemorrhage may lead to a hypovolemic shock state, tension pneumothorax may lead to an obstructive shock state, and urosepsis may lead to a septic shock state.
The nurse is assigned to care for a patient who had an epidural for a minor surgical procedure. The patient has developed a high fever and an increased heart rate. At last assessment, the patient's blood pressure was 89/58. The nurse should monitor the patient closely for additional signs of which type of shock? A. Septic shock B. Obstructive shock C. Neurogenic shock D. Cardiogenic shock
C. Neurogenic shock Rationale: Neurogenic shock can happen as a result of spinal anesthesia. The patient would display an increased heart rate, elevated body temperature, and a low blood pressure.
A patient's localized infection has become systemic and septic shock is suspected. What medication would be given to treat septic shock refractory to fluids? A. Insulin infusion B. Furosemide IV push C. Norepinephrine administered by titration D. Administration of nitrates and β-adrenergic blockers
C. Norepinephrine administered by titration Rationale: If fluid resuscitation using crystalloids is not effective, vasopressor medications, such as norepinephrine (Levophed) and dopamine, are indicated to restore mean arterial pressure (MAP). Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Furosemide (Lasix) is indicated for patients with fluid volume overload. Insulin infusion may be given to normalize blood sugar and improve overall outcomes, but it is not considered a medication used to treat shock.
Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Advocate for parenteral nutrition for patients who cannot take oral feedings. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. rationale: Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.
