TERM 4 Ch 37 Care of Patients with Shock
The nurse is preparing to administer a transfusion of packed red blood cells to a client with hemorrhagic shock. Which action is essential before initiating the transfusion? 1 Check the volume of blood in the bag. 2 Monitor the client for dark-colored urine. 3 Measure the client's blood pressure. 4 Initiate 0.9% saline solution infusion.
Initiate 0.9% saline solution infusion. Isotonic solutions such as Ringer's lactate or normal saline may be used as volume expanders in hypovolemic shock. Red blood cells must be given with 0.9% saline to prevent clotting during infusion. While the volume of the blood in the bag is approximately 250 mL, it may vary; however, this is not essential to validate before initiating the transfusion. The nurse monitors for dark urine when an ABO transfusion reaction is suspected. Vital signs, especially a baseline temperature, are indicated prior to transfusion; a low blood pressure during shock states is expected.
The client with which lab result is at risk for hemorrhagic shock? 1 International Normalized Ratio (INR) 7.9 2 Partial thromboplastin time (PTT) 12.5 seconds 3 Platelets 170,000/mm3 4 Hemoglobin 8.2 g/dL
International Normalized Ratio (INR) 7.9 Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.
Which finding contributes to an acidotic state in a client with septic shock? 1 Hemoglobin of 12 g/dL 2 Lactate level of 9.2 mmol/L 3 Platelet count of 150,000 cells/mm3 4 Peripheral oxygen saturation of 95%
Lactate level of 9.2 mmol/L Elevated lactate levels occur with anaerobic metabolism consistent with metabolic acidosis. Hemoglobin of 12 g/dL is within normal range and does not reflect disseminated intravascular coagulation (DIC), which may be found in clients with septic shock. Platelets are low, but may reflect DIC if they drop further, rather than metabolic acidosis. A pulse oximetry reading of 95% is a normal value and does not support hypoxemia or tissue hypoxia.
A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? 1 Administers oxygen therapy 2 Obtains the client's description of the chest discomfort 3 Provides pain relief medication 4 Remains calm and stays with the client
Obtains the client's description of the chest discomfort A description of the chest discomfort must be obtained first, before further action can be taken. Pain medication and oxygen therapy are not the first priority in this situation; an assessment is needed first. Remaining calm and staying with the client are important, but are not matters of highest priority.
A client in hypovolemic shock presents with a normal hematocrit and hemoglobin. What type of fluid should the nurse anticipate the healthcare provider will prescribe to restore oncotic pressure? 1 Plasma 2 Whole blood 3 Ringer's lactate 4 Packed red cells
Plasma The ideal intervention for restoring osmotic pressure in a client with normal hematocrit and hemoglobin is plasma. Plasma protein fractions and synthetic plasma expanders are used to increase fluid volume. Whole blood is suitable for replacing large blood losses in clients with a decrease in hemoglobin and hematocrit levels. Ringer's lactate does not restore oncotic pressure; it is a crystalloid that restores fluid volume and is used in instances where the client needs volume expansion and correction of acidosis. Packed red cells are chosen for moderate blood losses when the client needs red blood cells without added fluid volume.
Which problem places a client at highest risk for sepsis? 1 Pernicious anemia 2 Pericarditis 3 Post-kidney transplant 4 Client owns an iguana
Post-kidney transplant The post-kidney transplant client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney-transplant client has a very high risk for infection, sepsis, and death.
A client experiencing shock asks the nurse, "What is going to happen to me?" Which response is best for the nurse to convey? 1 "You seem quite anxious. What do you think will happen?" 2 "We are doing everything appropriate for your condition, and I am monitoring you closely." 3 "The shock condition is taking the blood away from your brain. That is why you are anxious." 4 "Your blood pressure is quite low, which happens when you lose a lot of blood."
"We are doing everything appropriate for your condition, and I am monitoring you closely." The client in shock should be reassured that appropriate treatment is being carried out. Reflecting the client's anxiety back to him or her at this time is not therapeutic, as the client has asked for information. Providing the physiologic rationale for the client's anxiety is not appropriate at this time, nor does it speak to the client's concerns. There is no indication that the client is losing blood, but in a shock state the blood pressure is low; however, this response does not answer the client's concern as to what will happen.
What are the actions of renin in the maintenance of blood pressure? Select all that apply. 1 Decrease urine output 2 Decrease sodium reabsorption 3 Constrict peripheral blood vessels 4 Stimulate cardiac pump activity 5 Increase blood potassium levels
-Decrease urine output -Constrict peripheral blood vessels Renin is produced in the body as a response to low blood pressure. This enzyme helps in maintaining blood pressure by decreasing urine output and constricting peripheral blood vessels. Renin also increases sodium reabsorption in the kidney which causes further retention of water. Renin does not directly affect cardiac function or potassium levels.
Which are risk factors for hypovolemic shock? Select all that apply. 1 Hemophilia 2 Malnutrition 3 Diuretic therapy 4 Spinal cord injury 5 Myocardial infarction
-Hemophilia -Malnutrition -Diuretic therapy Specific risk factors for hypovolemic shock include hemophilia, malnutrition, and diuretic therapy. Hypovolemia can be caused by impaired clotting in clients with hemophilia and malnourishment. Excessive diuresis due to diuretic therapy can also cause reduction in blood volume. Clients with spinal cord injury have distributive shock in which the total blood volume is not reduced but fluid shifts from the central vascular space. In clients with myocardial infarction, cardiac function is impaired which causes cardiogenic shock.
Which medications are often used to provide adrenal support for the client with severe sepsis? Select all that apply. 1 Penicillin 2 Levofloxacin (Levoquin) 3 Hydrocortisone (Solu-cortef) 4 Fludrocortisone (Florinef) 5 Vancomycin (Vancocin)
-Hydrocortisone (Solu-cortef) -Fludrocortisone (Florinef) During severe sepsis, the body's immune response can become self-destructive if not controlled. Drugs that provide adrenal support during severe sepsis are IV hydrocortisone and oral fludrocortisone. IV penicillin, levofloxacin, and vancomycin are antibiotics that help to kill the bacteria causing the sepsis.
Which are cardiovascular manifestations of hypovolemic shock? Select all that apply. 1 Narrow pulse pressure 2 Postural hypotension 3 Decreased pulse rate 4 Decreased cardiac output 5 Bounding peripheral pulses
-Narrow pulse pressure -Postural hypotension -Decreased cardiac output In hypovolemic shock, total body fluid is reduced; therefore, the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.
A 70-year-old client is admitted after a spider bite to the finger 12 hours ago. Which of these assessment data suggest the client has sepsis? Select all that apply. 1 Respiratory rate 2 Blood pressure 3 Breath sounds 4 Serum glucose 5 Anxiety 6 Serum potassium
-Respiratory rate -Blood pressure -Serum glucose Clients with sepsis present with a cluster of symptom manifestations in response to a systemic infection. Symptoms consistent with inflammation (tachycardia, tachypnea, temperature, white blood cell change) and additional clinical manifestations (hypotension, decreased urine output, positive fluid balance, decreased capillary refill, hyperglycemia, mental status change, increased serum creatinine) are seen in clients with sepsis.
The client in shock has the following vital signs: T 99.8° F, P 132, R 32, and BP 80/58. Calculate the pulse pressure. Record as a whole number.
22 Pulse pressure is the difference between the systolic and diastolic pressures. 80 (systolic) - 58 (diastolic) = 22 (pulse pressure)
After norepinephrine (Levophed) is administered to a client with hypovolemic shock, which assessment factor is used to verify the effectiveness of the treatment? 1 Blood pressure 2 Urinary output 3 Level of consciousness 4 Blood glucose
Blood pressure Norepinephrine (Levophed) is a vasoconstrictor drug used in hypovolemic shock to increase perfusion and oxygenation. These drugs constrict the blood vessels and increase venous return. Urine production will not increase until blood pressure rises and perfuses the kidneys. Norepinephrine does not have any effect on a client's level of consciousness or blood glucose levels.
The nurse is administering continuous intravenous infusion of norepinephrine (Levophed) to a client in shock. Which finding causes the nurse to decrease the rate of infusion? 1 Blood pressure 170/96 mm Hg 2 Respiratory rate 22 breaths/min 3 Urine output of 70 mL/hr 4 Heart rate 98 beats/min
Blood pressure 170/96 mm Hg Signs of excess vasoconstricting drugs include headache, hypertension, and decreased renal perfusion manifested by oliguria. While vasoconstricting medications and the shock state may cause tachycardia (heart rate greater than 100 beats/min), this client's heart rate is within normal range. Vasoconstricting drugs do not affect the respiratory rate; shock itself causes an increased respiratory rate in an effort to deliver more oxygen to the tissues.
A client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? 1 Broad-spectrum antibiotics 2 Blood transfusion 3 Cooling baths 4 Nothing by mouth (NPO) status
Broad-spectrum antibiotics Broad-spectrum antibiotics must be initiated within 1 hour of establishing diagnosis. A blood transfusion is indicated for low red blood cell (RBC) count or low hemoglobin and hematocrit; transfusion is not part of the sepsis resuscitation bundle. Cooling baths are not indicated because the client is hypothermic, nor is this part of the sepsis resuscitation bundle. NPO status is not indicated for this client, nor is it part of the sepsis resuscitation bundle.
A client with hypovolemic shock has these vital signs: temperature 97.9° F; pulse 122 beats/min; blood pressure 86/48 mm Hg; respirations 24/min; urine output 20 mL for last 2 hours; skin cool and clammy. Which medication order for this client does the nurse question? 1 Dopamine (Intropin) 12 mcg/kg/min 2 Dobutamine (Dobutrex) 5 mcg/kg/min 3 Plasmanate 1 unit 4 Bumetamide (Bumex) 1 mg IV
Bumetamide (Bumex) 1 mg IV A diuretic like bumetamide will decrease blood volume in a client who is already hypovolemic; this order should be questioned because this is not an appropriate action to expand the client's blood volume. The other orders are appropriate for improving blood pressure in shock, and do not need to be questioned.
Which of these individuals may be at highest risk for hypovolemic shock? 1 Client with acute kidney failure 2 Client with myocardial infarction 3 Client who overdosed on bumetamide (Bumex) 4 Client with benign prostatic hyperplasia (BPH)
Client who overdosed on bumetamide (Bumex) Hypovolemic shock results from decreased circulating blood volume; bumetamide, a potent loop diuretic, decreases blood volume. A myocardial infarction may lead to cardiogenic shock or heart failure, with resulting fluid volume excess rather than hypovolemia. Kidney failure results in increased blood volume (hypervolemia) as the failing kidney is unable to produce urine. BPH obstructs the outflow of urine into the bladder as prostatic tissue enlarges; blood volume is not reduced.
How is a client with systemic inflammatory response syndrome (SIRS) differentiated from a client with sepsis? 1 Client with sepsis has hypotension. 2 Client with sepsis has a negative fluid balance. 3 Client with SIRS has hyperglycemia. 4 Client with SIRS has an elevated creatinine level.
Client with sepsis has hypotension. The client with sepsis has two or more SIRS criteria and one of the following: hypotension, oliguria, positive fluid balance, decreased capillary refill, hyperglycemia, change in mental status, or increasing creatinine. The SIRS criteria include temperature of >100.4° F or < 96.8° F, pulse >90 beats/min, respiratory rate >20 breaths/min or a Paco2 12,000/mm3 or 3.
Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? 1 Client receiving a blood transfusion 2 Client with severe ascites 3 Client with myocardial infarction 4 Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion
Client with severe ascites Fluid shifts from vascular to intraabdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess ADH secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.
Which laboratory result is seen in late sepsis? 1 Decreased serum lactate 2 Decreased segmented neutrophil count 3 Increased numbers of monocytes 4 Increased platelet count
Decreased segmented neutrophil count A decreased segmented neutrophil count is indicative of late sepsis. Serum lactate is increased in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis; late in sepsis, platelets may decrease due to consumptive coagulopathy.
Which sign of hypovolemic shock does the nurse instruct the client who had an outpatient surgical procedure to report immediately? 1 Dizziness 2 Lack of appetite 3 Mild pain at the site of the procedure 4 1-cm clear yellow drainage from incision
Dizziness Dizziness or lightheadedness may indicate hypotension and possible shock. Thirst, rather than anorexia, is a symptom of hypovolemic shock. Mild pain may occur after a surgical procedure, but increases in pain should be reported because this may indicate further bleeding with tissue compression. Obvious bleeding, rather than serous drainage, should be reported to the provider.
When caring for a client with septic shock who has disseminated intravascular coagulation (DIC), the nurse anticipates which finding? 1 Polycythemia 2 Thrombocytosis 3 Elevated d-dimer levels 4 Elevated fibrinogen levels
Elevated d-dimer levels Plasma d-dimer levels rise during DIC as multiple fibrin clots break down. A reduction in red blood cells, hemoglobin, and hematocrit, rather than an increase (polycythemia), occur in DIC. Thrombocytopenia (a reduction of platelets) rather than thrombocytosis (an increased number of platelets) occurs along with reduced fibrinogen levels as these components are incorporated into the multiple small clots that develop in DIC.
A client in the progressive or intermediate stage of hypovolemic shock will exhibit which manifestation? 1 Polyuria 2 Metabolic alkalosis 3 Moist, warm skin 4 Feeling of impending doom
Feeling of impending doom As shock progresses, tissue perfusion to the brain continues to be reduced, causing a sense of anxiety or that "something bad" is about to happen. Oliguria or anuria occurs in the nonprogressive stage rather than polyuria. A lack of perfusion to the skin results in cool, moist skin rather than warm skin. Due to decreased tissue perfusion, buildup of lactic or metabolic acid occurs; the arterial blood gases reflect metabolic acidosis at this time.
A client in hypovolemic shock has been placed on an infusion of the vasopressor agent norepinephrine (Levophed). Which parameter indicates a desired client response to the therapy? 1 Heart rate change from 112 to 123 beats/min 2 Decreased peripheral pulses 3 Mean arterial pressure change from 66 to 78 mm Hg 4 Urine output remains at 30 mL/hour
Mean arterial pressure change from 66 to 78 mm Hg If fluid therapy is not effective in increasing blood pressure, vasoconstricting drugs may be added to increase tissue perfusion. When vasoactive agents are administered, the nurse monitors for effectiveness by evaluating improvements in cardiac output and mean arterial pressure. An increase, not decrease, in urine output is a desired response. An increased heart rate is expected due to sympathetic nervous system stimulation of norepinephrine. Decreased peripheral pulses may occur due to vasoconstrictor effects, but it is not a desired response.
The nurse in the postanesthesia care unit is caring for a postoperative client whose heart rate suddenly increases to 122 beats/min and the blood pressure drops to 84/48 mm Hg. Which position does the nurse use to improve the client's blood pressure and organ perfusion? 1 Sims' 2 Lithotomy 3 Modified Trendelenburg 4 Head of bed 30 degrees, legs flat
Modified Trendelenburg Maintaining the client flat with the feet elevated (modified Trendelenburg) improves venous return and perfusion to the brain. Sims' position refers to lying on the left side with the top leg flexed, typically used for enemas and GI procedures. The lithotomy position is used for gynecologic examination and procedures. The head of bed elevated at 30 degrees describes a semi-Fowler's position used to prevent aspiration.
A client who underwent a radical colon resection for metastatic cancer has developed septic shock and remains neurologically unresponsive, unable to breathe without mechanical ventilator support, requires dialysis for renal function, is not tolerating tube feedings, and is beginning to show signs of hepatic failure. What condition does the nurse suspect the client has developed based on these clinical manifestations? 1 Late stage of septic shock 2 Multiple organ dysfunction syndrome (MODS) 3 Intercerebral hemorrhage 4 Adverse reaction to sedating agents
Multiple organ dysfunction syndrome (MODS) Shock that progresses to the refractory stage causes irreversible cell death and tissue damage, releasing toxic metabolites that cause organs to fail. Once the sequence of multiple organs begins to fail because of the buildup of metabolites and toxins, the client's condition is termed multiple organ dysfunction syndrome. MODS involves the presence of altered organ functions in two or more organ systems. In this client, four organs have "failed' with a fifth (the liver) imminent.
A client is scheduled for thoracotomy later today. Which entry noted on the medication reconciliation record poses a risk for perioperative hemorrhagic shock and causes the nurse to contact the provider immediately? 1 Captopril (Catapres) 2 Furosemide (Lasix) 3 Naproxen (Naprosyn) 4 Omeprazole (Prilosec)
Naproxen (Naprosyn) Naproxen is a nonsteroidal antiinflammatory agent that poses a risk for bleeding. Captopril (for hypertension), furosemide (for heart failure), or omeprazole (prevents gastroesophageal reflux disease and gastrointestinal bleeding from stomach ulcers) do not pose risks for bleeding. Anticoagulants, aspirin, and NSAIDs should be questioned.
A client is admitted with new-onset hypotension, tachycardia, tachypnea, and elevated white blood cell count, but blood cultures are negative. The client is becoming increasingly confused. What is the nurse's best action? 1 Notify the Rapid Response Team. 2 Establish an IV for possible fluid administration. 3 Activate the bed alarm. 4 Reorient the client frequently.
Notify the Rapid Response Team. Systemic inflammatory response syndrome (SIRS) manifests similarly to sepsis in which the client is underperfused, but an infectious cause may not be present. Worsening confusion suggests the client is progressing in shock state and a Rapid Response Team should be called to assess and treat the client's hypoperfusion. Establishing an IV for fluid administration is an appropriate action, but not before calling the Rapid Response Team. Reorienting the client and activating the bed alarm will not address the underlying cause of the confusion.
What is the component of colloid solutions that is helpful in managing hypovolemic shock through the intravenous route? 1 Salts 2 Sugars 3 Starches 4 Minerals
Starches Colloid solutions are mainly composed of larger molecules like starches and proteins. These molecules help to maintain the oncotic pressure of the intravascular fluid and prevent fluid loss. Salts, sugars, and minerals are components of crystalloids, not colloids.
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? 1 Hypotension 2 Bradypnea 3 Heart blocks 4 Tachycardia
Tachycardia Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.
What typical sign/symptom indicates the early stage of septic shock? 1 Pallor and cool skin 2 Blood pressure 84/50 mm Hg 3 Tachypnea and tachycardia 4 Respiratory acidosis
Tachypnea and tachycardia Signs of systemic inflammatory response syndrome, which precede sepsis, include rapid respiratory rate, leukocytosis, and tachycardia. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis occurs early in shock because of an increased respiratory rate.
A client recovering from an open reduction of the femur suddenly feels lightheaded, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? 1 Temperature 2 Pulse 3 Respiration 4 Blood pressure
Temperature A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.
Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? 1 The LPN/LVN who has 20 years of experience 2 The new RN who recently finished orienting and is working independently with moderately complex clients 3 The RN who will also be caring for a client who had coronary artery bypass grafting (CABG) 12 hours ago 4 The RN with 2 years of experience in intensive care
The RN with 2 years of experience in intensive care The RN with current intensive care experience who is not caring for a postoperative client would be an appropriate assignment. Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. The client who is experiencing septic shock is too complex for the new RN. Although the RN is experienced, this assignment will put the post-CABG client at risk for MRSA infection.
Which vital sign change in a client with hypovolemic shock indicates to the nurse that the fluid resuscitation therapy is effective? 1 Urine output increase from 5 to 35 mL/hr 2 Heart rate increase from 62 to 76 beats/min 3 Respiratory rate increase from 22 to 26 breaths/min 4 Core body temperature decrease from 98.8° F (37.1° C) to 98.2° F (36.8° C)
Urine output increase from 5 to 35 mL/hr During shock, the kidneys and baroreceptors sense an ongoing decrease in mean arterial pressure and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase. An increase in respiratory rate, increase in heart rate, and a decrease in core body temperature are not expected findings of successful fluid resuscitation.
A client is receiving antineoplastic chemotherapy. Which measure does the nurse teach that will help prevent infection and sepsis? 1 Drink only bottled water. 2 Use disposable dishes. 3 Wash the dishes in the dishwasher. 4 Avoid being in the same room as the family pet.
Wash the dishes in the dishwasher. Dishes should be washed in hot, soapy water or in a dishwasher to thoroughly cleanse them; there is no need to use disposable tableware. Water that has been standing longer than 15 minutes should be discarded; however, bottled water is not necessary. The client may be in the same room as, as well as touch, the family pet (with the exception of changing a litterbox—this should not be done); however, the client should wash the hands thoroughly with an antimicrobial soap after touching pets.
