SHOCK<SIRS<MODS
The answer is C. This type of shock is characterized by low HR and low BP
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).
The correct answer is 27 mL/hr. Do the math.
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?
The answer is A. Diuretics will reduce renal perfusion in a patient with shock - the patient will have an already decreased perfusion to this organ so we do not want to enhance that.
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.
The answered are B, C, D, E Interventions to be implemented immediately include: starting an IV fluid bolus of 0.9% Normal Saline to help increase the client's body fluids and increase BP, inserting a 16F Foley catheter to monitor accurate urinary output, placing the client flat to help increase the BP, and starting a second IV of Norepinephrine to help raise the client's BP. Raising the client's HOB will decrease the client's BP even more and should be avoided.
A client from a nursing home is sent to the emergency department for a massive GI bleed. The client has cold and clammy skin, BP 80/40, HR 128, RR 28, and urine output less than 10 ml/hr. Which of these interventions should be implemented immediately? Select all that apply. A. Place the client in high fowler's B. Start an IV fluid bolus of 0.9% NS C. Insert a foley catheter D. Place the client in a flat position E. Start a second IV of Norepinephrine
The answer is D. MAP and CVP are low for a client in shock, and tissues are not being adequately perfused. Fluid status should be the first thing to correct, as CVP is the best indicator for that. (normal is 8-12)
A client in shock develops a CVP of 2mmHg. Which intervention should the nurse implement first? A. Increase O2 flow rate B. Obtain ABG's C. Insert a foley catheter D. Increase rate of IVF
The answers are A, B. In cardiogenic shock, the heart fails to pump effectively enough to supply the body's needs. Cardiogenic shock can be caused from a heart attack or myocardial infarction. The goal of treatment would be to restore heart function as well as blood pressure quickly. Medication interventions used to treat cardiogenic shock may include dopamine and digoxin. Both are positive inotropic meds that cause the heart to generate more forceful beats. Dopamine improves heart contractility and the choice for hypotensive clients. Digoxin "digs" for a deeper contraction and is a cardiac glycoside.
A client is admitted to the unit with cardiogenic shock from a heart attack. After receiving health care provider orders, which intervention medications will the nurse anticipate preparing? Select all that apply. A. Dopamine B. Digoxin C. Diphenhydramine D. Daunorubicin E. Dexamethasone
The answer is D. Neurogenic shock refers to a spinal cord injury associated with autonomic dysregulation. Neurogenic shock is caused by a lack of blood flow throughout the client's body. The sympathetic nervous system usually maintains expected muscle tone in the body, but suddenly the signal is lost causing relaxed dilated blood vessels resulting in blood pooling in our venous system creating a decreased blood pressure and bradycardia. Symptoms associated with neurogenic shock and commonly seen are hypotension, bradycardia, and difficulty breathing. Blood pressure is normally systolic below 80.
A client is brought to the emergency department with a T5 spinal cord injury from a car wreck. Which of these vital signs should the nurse expect to see the client exhibiting? A. HR 120, RR 20, BP 100/68 B. HR 100, RR 16, BP 120/72 C. HR 62, RR 18, BP 110/50 D. HR 50, RR 32, BP 78/45
The correct answers are A, D, E. The client is experiencing anaphylactic shock and therefore the priority is to stop the infusion and rapidly intervene. Raising HOB would worsen low BP.
A client receiving thrombolytics via IV infusion suddenly becomes anxious and reports itching. The nurse auscultates and hears stridor in the lungs, marked hypotension, and urticaria. What interventions are the priority? Select all that apply: A. Stop the infusion B. Raise the HOB C. Administer Protamine Sulfate D. Administer Diphenhydramine E. Call for a Rapid Response
The answer is A. Clinical signs of cardiogenic shock include low BP, rapid, weak pulse, low UO, cool clammy skin, increased RR, and onset of metabolic acidosis.
A client with chest pain suspected of MI related to elevated Troponin levels had the following vitals signs at admission: 92bpm, 24 breaths/min, 140/88. An hour later, the vitals were reassessed to be 118 bpm, 32 breaths/min, and 88/58. This change in vitals signs is most likely due to what complication? A. Cardiogenic Shock B. Cardiac Tamponade C. Pulmonary Embolism D. Dissecting Thoracic Aortic Aneurysm
The answer is A. The client already has pneumonia with a urinary tract infection. Sepsis results when an infection enters the bloodstream causing serious complications, such as weakness, chills, high fever, tachycardia, tachypnea, hypotension. These can lead to septic shock if left unchecked causing severe hypotension and organs to shut down
A client with pneumonia has vitals of 102.5*, 70/38, 140bpm, 38 breaths/min, is complaining of weakness and chills. Further assessment revealed slow capillary refill, cool and clammy skin and the WBC count is 19k. What does the nurse expect the diagnosis to be? A. Septic shock from sepsis B. Cardiogenic shock from heart failure C. Anaphylactic shock from a drug reaction D. Neurogenic shock from a spinal cord injury
The answer is B. Recall that in stage 1, the client is in the compensatory phase with no change in BP; stage 2 consists of a marked change in BP, lower CO; stage 3 is characterized by edema, cardiac abnormalities, weak pulses, extremely low BP; stage 4 is characterized by lack of response to treatment.
A client with pneumonia is at risk for shock. The nurse notices the client become restless, agitated, and confused, has a low UO and a BP of 92/68. The nurse should suspect this patient is in which stage of shock? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
The answer is C. Warm, pink, and dry is good in terms of assessing for perfusion - since Nitroprusside is a vasodilator, you would expect the desired effect to be to have increased overall tissue perfusion which includes the skin.
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
The answer is A. PAWP and CVP indicate excessive fluid, therefore giving an infusion of NS will only worsen the FV overload.
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.
c. If the metabolic acidosis is compensated, the pH will be within the normal range. If the patient is hyperventilatingto blow off carbon dioxide to reduce the acid load of the blood, PaCO2 will be decreased
A patient in the progressive stage of shock has rapid, deep respirations. The nurse determines that the patient's hyperventilation is compensating for a metabolic acidosis when the patient's arterial blood gas (ABG) results include which results? a. pH 7.42, PaO2 80 mm Hg b. pH 7.48, PaO2 69 mm Hg c. pH 7.38, PaCO2 30 mm Hg d. pH 7.32, PaCO2 48 mm Hg
The answer is A. ABC's - focus on giving O2 first.
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.
The answer is C. Priority is to maintain airway and oxygenation. ABC's.
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.
b. Generally, the first body system affected by mediator- induced injury in MODS is the respiratory system. Adventitious sounds and areas with absent breath sounds will be present. Other organ damage occurs but lungs are usually first.
A patient with a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the patient for early organ damage associated with MODS, what is most important for the nurse to assess? a. Urine output c. Peripheral circulation b. Breath sounds d. Central venous pressure
d. In every type of shock there is a deficiency of oxygen to the cells and high-flow oxygen therapy is indicated. Fluids would be started next, blood cultures would be done before any antibiotic therapy, and laboratory specimens then could be drawn
A patient with acute pancreatitis is experiencing hypovolemic shock. Which initial orders for the patient will the nurse implement first? a. Start 1000 mL of normal saline at 500 mL/hr. b. Obtain blood cultures before starting IV antibiotics. c. Draw blood for hematology and coagulation factors. d. Administer high-flow oxygen (100%) with a non-rebreather mask.
The answer is B. PAWP indicates a high preload, therefore furosemide would be indicated to reduce pressure within the cardiopulmonary system and to increase CO.
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)
The answer is A. Fluid resuscitation is important and is the first line of treatment in septic shock because of the significant decrease in SVR (blood flow to the systemic).
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.
b. During both the compensatory and the progressive stages of shock, the sympathetic nervous system is activated inan attempt to maintain CO and SVR. In the irreversible stage of shock, the sympathetic nervous system can no longer compensate to maintain homeostasis and a loss of vasomotor tone leading to profound hypotension affects perfusion to all vital organs, causing increasing cellular hypoxia, metabolic acidosis, and cellular death.
A patient with severe trauma has been treated for hypovolemic shock. The nurse recognizes that the patient is in the irreversible stage of shock when what is included in assessment findings? a. A lactic acidosis with a pH of 7.32 b. Marked hypotension and refractory hypoxemia c. Unresponsiveness that responds only to painful stimuli d. Profound vasoconstriction with absent peripheral pulses
The correct answers are ABDE. Never give large amounts of fluid in shock
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.
The answer is B. ABX first! Within one hour of diagnosis.
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
The answer is B. Vasopressors can help to increase BP, SVR, and perfusion if fluid does not resolve pressure issues. Nitroglycerin is a vasodilator and will decrease CO, BP, and preload. Nitroprusside is a vasodilator and will decrease SVR. Steroids are only considered if fluids AND vasopressors do not work.
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).
The answer is C. Low PLT and presence of petechiae can indicate the patient has DIC and MODS
After reviewing the information below for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Low platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate.
The answer is C. Nitroprusside is a vasodilator will significantly lower SVR/afterload, therefore improving overall cardiac output. Dopamine is a vasopressor and will increase SVR.
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.
d. Angiotensin II vasoconstricts both arteries and veins, which increases blood pressure (BP). It stimulates aldosterone release from the adrenal cortex, whichresults in sodium and water reabsorption and potassium excretion by the kidneys. The increased sodium raises serum osmolality and stimulates the pituitary gland to release antidiuretic hormone (ADH), which increases water reabsorption, which further increases blood volume, leading to an increase in BP and CO
As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic change occurs related to the increased angiotensin II? a. Vasodilation b. Decreased blood pressure (BP) and CO c. Aldosterone release results in sodium and water excretion d. Antidiuretic hormone (ADH) release increases water reabsorpton
The answer is A. Change in LOC indicates progressive shock and requires rapid intervention, the other choices are of the compensatory stage.
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
The answer is A. Fluids must be given before vasopressors can be initiated, therefore a patient with CVP of 3 (normal is 8-12) is at a fluid deficit and requires fluid first.
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.
d. Decreased myocardial perfusion leads to dysrhythmias and myocardial ischemia, further decreasing CO and oxygen delivery to cells. The kidney's renin-angiotensin- aldosterone system activation causes arteriolar constriction that decreases perfusion. In the lung, vasoconstriction of arterioles decreases blood flow and a ventilation-perfusion mismatch occurs. Areas of the lung that are oxygenated are not perfused because of the decreased blood flow, resulting in hypoxemia and decreased oxygen for cells. Increased capillary permeability and vasoconstriction cause increased hydrostatic pressure that contributes to the fluid shifting to interstitial spaces.
Progressive tissue hypoxia leading to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contribute to this increasing tissue hypoxia? a. Arterial constriction causes decreased perfusion. b. Vasoconstriction decreases blood flow to pulmonary capillaries. c. Increased capillary permeability and profound vasoconstriction cause increased hydrostatic pressure. d. Decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells.
The answer is A. Anaphylactic shock is shock caused by an allergic reaction to a toxin. When the body is hypersensitive to an antigen, the body stimulates the immune system to kick in and respond. Symptoms may include hives over the body, dyspnea (shallow fast respirations), hypotension, tachycardia, anxiety, clammy skin, confusion, and loss of consciousness. Epinephrine (Epi-pen) is a priority to implement. Diphenhydramine is usually given next; then albuterol and steroids.
The ambulance brings a client with multiple bee stings to the ED. The client is exhibiting dyspnea, hives over the body, and hypotension. Which of these would the nurse implement as priority? A. Epinephrine B. Albuterol Sulfate C. Dexamethasone D. Diphenhydramine
The answer is C. This patient likely requires fluid and/or blood products therefore two IV's are necessary
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.
The answer is B. Epi is given to rapidly induce vasoconstriction, bronchodilation, and block vasodilatory and bronchoconstricting action of anaphylaxis
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).
The correct order is E, D, C, A, B. Remember ABC's first, then go for the treatment of the cause.
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? 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%.
The answer is A. The client is likely experiencing cardiogenic shock and requires medication to increase cardiac function.
The nurse is caring for a client with heart failure exacerbation and suspects the client may be in shock. What is the priority intervention for this patient? A. Administer digoxin B. Administer whole blood C. Administer IV fluids D. Administer PRBC
The answer is B. Skin cool and clammy is a sign of worsening septic shock - in early stages, skin will be warm and dry.
The nurse is caring for a patient who has septic shock. Which assessment finding change should warrant a 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
a, c, f. In the compensatory stage of shock the patient's skin will be pale and cool (α-adrenergic stimulation). There may also be a change in level of consciousness but the person will be responsive, the BP will be lower than baseline, bowel sounds will be hypoactive (α-adrenergic stimulation), and tachypnea and tachycardia (β-adrenergic stimulation) will occur. Unresponsiveness and moist crackles in the lungs occur in the progressive stage of shock
The patient is in the compensatory stage of shock. What manifestations indicate this to the nurse (select all that apply)? a. Pale and cool b. Unresponsive c. Lower BP than baseline d. Moist crackles in the lungs e. Hyperactive bowel sounds f. Tachypnea and tachycardia
The answer is C. Coolness and pallor at the IV indicates extravasation - D/C IV, get a central line.
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.
The answer is D. PPI help reduce stress ulcers in critical patients - the presence of blood would indicate the PPI's are NOT effective.
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.
c. Prevention of shock necessitates identification of persons who are at risk and a thorough baseline nursing assessment with frequent ongoing assessments to monitor and detect changes in patients at risk. Frequent monitoring of all patients' vital signs is not necessary. Aseptic technique for all invasive procedures should always be implemented but will not prevent all types of shock. Health promotion activities that reduce the risk for precipitating conditions, such as coronary artery disease or anaphylaxis, may help to prevent shock in some cases.
What is the priority nursing responsibility in the prevention of shock? a. Frequently monitoring all patients' vital signs b. Using aseptic technique for all invasive procedures c. Being aware of the potential for shock in all patients at risk d. Teaching patients health promotion activities to prevent shock
d. The ischemic or necrotic tissue mechanism triggersSIRS with myocardial infarction, pancreatitis, and vascular disease. Endotoxin release is seen with gram-negative and gram-positive bacteria. The abscess formation mechanism occurs with intraabdominal and extremitiy abscesses. Global perfusion deficits are seen post-cardiac resuscitation and in shock states.
What mechanism that can trigger SIRS is related to myocardial infarction or pancreatitis? a. Endotoxin release b. Abscess formation c. Global perfusion deficits d. Ischemic or necrotic tissue
a, b, e, f. Hypovolemic shock occurs when there is aloss of intravascular fluid volume from fluid loss (as in hemorrhage or severe vomiting and diarrhea), fluid shift (as in burns or ascites), or internal bleeding (as with a ruptured spleen). Vaccines and insect bites would precipitate the anaphylactic type of distributive shock
What physical problems could precipitate hypovolemic shock (select all that apply)? a. Burns b. Ascites c. Vaccines d. Insect bites e. Hemorrhage f. Ruptured spleen
a, d, e. Mechanical tissue trauma triggering of SIRS occurs with burns, surgical procedures, and crush injuries. Fungi, viruses, bacteria, and parasites cause microbial invasion.
What types of injuries cause a mechanical tissue trauma that can trigger SIRS (select all that apply)? a. Burns b. Fungi c. Viruses d. Crush injuries e. Surgical procedures
a. A decreased mixed venous oxygen saturation (SvO2) indicates that the patient has used the venous oxygen reserve and is at greater risk for anaerobic metabolism. The SvO2 decreases when more oxygen is used by the cells, as in activity or hypermetabolism. All of the other values indicate an improvement in the patient's condition.
When caring for a patient in cardiogenic shock, the nurse recognizes that the metabolic demands of turning and moving the patient exceed the oxygen supply when what change is revealed in hemodynamic monitoring? a. SvO2 from 62% to 54% b. CO from 4.2 L/min to 4.8 L/min c. Stroke volume (SV) from 52 to 68 mL/beat d. SVR from 1300 dyne/sec/cm5 to 1120 dyne/sec/cm5
The answer is D. Patients with this form of shock tend to have "poikilothermia" therefore keeping the room warm is extremely important to avoid hypothermia.
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
The answer is D. O2 sats are the most appropriate way to determine that perfusion is adequate because of the effects edema can cause during anaphylaxis.
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
The correct answers are C, D, E. Sepsis diagnostic criteria includes: -fever greater than 100.9 or less than 97 -tachycardia greater than 90 bpm -tachypnea greater than 22 breaths/min -SBP less than or equal to 100 mmHg -altered LOC -edema or increased fluid balance -oliguria -absent bowel sounds (ileus) -decreased cap refill -mottled skin
Which clinical findings are consistent with sepsis diagnostic criteria? A. Urine output 50 mL/hr B. Hypoactive bowel sounds C. Temperature of 102* F D. HR of 96 bpm E. MAP of 60 mmHg F. SBP of 110 mmHg
The answer is A. Creatinine increase indicates renal failure and impending heart failure, which is a precursory sign of MODS.
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.
The answer is C. Vasopressin can significantly reduce coronary perfusion and requires swift intervention because of the risk for MI.
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.
The answer is C. Assessment of UO is the best indictor to show good ORGAN perfusion - the other choices are good but do not determine that fluid resuscitation was effective.
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 Hg.
a, b, c, e, f. Skin (color, temperature, moisture), urine output, level of consciousness, vital signs (including pulse oximetry), and peripheral pulses with capillary refill should be monitored to evaluate tissue perfusion.
Which indicators of tissue perfusion should be monitored in critically ill patients by the nurse (select all that apply)? a. Skin b. Urine output c. Level of consciousness d. Activities of daily living e. Vital signs, including pulse oximetry f. Peripheral pulses with capillary refill
a. Early enteral feedings in the patient in shock increase the blood supply to the GI tract and help to prevent translocation of GI bacteria and endotoxins into the blood, preventing initial or additional infection. Surgical removal of necrotic tissue, especially from burns, eliminates a source of infection in critically ill patients, as does the use of strict aseptic technique in all patient procedures. Known infections are treated with specific agents and broad-spectrum agents are used only until organisms are identified.
Which intervention may prevent GI bacterial and endotoxin translocation in a critically ill patient with SIRS? a. Early enteral feedings c. Aggressive multiple antibiotic therapy b. Surgical removal of necrotic tissue d. Strict aseptic technique in all procedures
The answer is B. Assess breath sound frequently for a patient who's pump is ineffective, since pulmonary congestion and dyspnea are symptoms of cardiogenic shock.
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.
c, d, e. Antihistamines, oxygen supplementation, and colloid volume expansion are used to treat anaphylactic shock. Epinephrine, a vasopressor, is also frequently used. Only septic shock is treated with antibiotics. Vasodilators and inotropes are only used for cardiogenic shock. Volume expansion fluids vary with each type of shock.
Which interventions should be used for anaphylactic shock (select all that apply)? a. Antibiotics b. Vasodilator c. Antihistamine d. Oxygen supplementation e. Colloid volume expansion f. Crystalloid volume expansion
b. The presence of MODS is confirmed when there is defined clinical evidence of failure of two or more organs. Elevated serum bilirubin indicates liver dysfunction, a serum creatinine of 3.8 mg/dL indicates kidney injury, and a platelet count of 15,000/μL indicates hematologic failure. Other criteria include urine output less than 0.5 mL/kg/hr, blood urea nitrogen (BUN) ≥100 mg/dL, white blood cell (WBC) count >10000/μL, upper or lower GI bleeding, Glasgow Coma Scale (GCS) score ≤6, and Hct ≤20%. A respiratory rate of 45, PaCO2 of 60 mm Hg, and chest x-ray with bilateral diffuse patchy infiltrates indicate respiratory failure but not other organ damage.
Which patient manifestations confirm the development of MODS? a. Upper GI bleeding, Glasgow Coma Scale (GCS) score of 7, and Hct of 25% b. Elevated serum bilirubin, serum creatinine of 3.8 mg/dL, and platelet count of 15,000/μL c. Urine output of 30 mL/hr, BUN of 45 mg/dL, and white blood cell (WBC) count of 1120/μL d. Respiratory rate of 45, PaCO2 of 60 mm Hg, and chest x-ray with bilateral diffuse patchy infiltrates
The correct answers are ABCE. You want enteral, not parenteral. Support the gut while it is still functioning.
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.
d. A common initial mediator that causes endothelial damage leading to systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is endotoxin. MODS results from SIRS. Not all patients with septic shock develop MODS, although they do have SIRS. The respiratory system is frequently the first to show evidence of SIRS and MODS.
Which statement describing systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is accurate? a. MODS may occur independently from SIRS. b. All patients with septic shock develop MODS. c. The GI system is often the first to show evidence of dysfunction in SIRS and MODS. d. A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin.