Unit 1 Perfusion***

Ejection Fraction (EF)

% of blood volume in ventricles at the end of diastole that is ejected during systole; -contractility 55%-65%, outside of range indicates systolic dysfunction

Pulmonary artery wedge pressure (PAWP)

- aka L end diastolic pressure, measures pulmonary capillary pressure. Preload - 6-12 mmHg - If elevated, think left sided hf, cardiogenic shock - decreased=all other shock

Cardiac Output (CO)

- amt of blood pumped from ventricles in 1 min -assesses cardiac performance *LV* - normal cardiac output is 4 to 8 L/min, lowers during shock (heart failure) - SV x HR

Central Venous Pressure (CVP)

- measures RV preload, circulating fluid volume - CVP normal range 8-12 mmHg - high CVP will always have a negative impact on venous return and capillary blood flow, right ventricular failure or volume overload, cardiogenic shock - low CVP indicates hypovolaemia, neurogenic, septic, or anaphylactic shock

A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take? 1.Call the primary health care provider immediately. 2.Document these findings, which are expected. 3.Re-evaluate the neurovascular status in 1 hour. 4.Increase the rate of the intravenous nitroglycerin infusion.

1. Call the primary health care provider immediately. The nursing interventions for the client with an intra-aortic balloon pump are the same as for any client who has had cardiovascular surgery. The peripheral circulation to the affected limb is monitored for signs of occlusion, such as coolness, mottling, pain, tingling, and decreased or absent distal pulse. Adverse changes are reported immediately. The remaining options are incorrect.

When caring for a patient in acute septic shock, what should the nurse anticipate? 1.Infusing large amounts of IV fluids 2.Administering osmotic and/or loop diuretics 3.Administering IV diphenhydramine (Benadryl) 4.Assisting with insertion of a ventricular assist device (VAD)

1. Infusing large amounts of IV fluids Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of 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.

An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse should determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range? 1.56% (0.56) 2.48% (0.48) 3.37% (0.38) 4.34% (0.34)

2. 48% (0.48) The normal hematocrit level for an adult male is 42% to 52% (0.42 to 0.52). The client who is in shock has an elevated level because of hemoconcentration. The client's level may be expected to drift back down to within the normal range once fluid volume has been adequately restored. Thus, 48% (0.48) is the only correct choice; 56% (0.56) is too high, and 34% (0.34) and 37% (0.37) are low.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1.A pregnant woman who exclaims, "My baby is not moving." 2.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2. A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The victim who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the victim is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.

A 50-yr-old woman with a suspected brain tumor is scheduled for a CT scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? 1.Infuse IV diphenhydramine before the procedure. 2.Administer lorazepam (Ativan) before the procedure. 3.Complete the CT scan without the use of contrast media. 4.Premedicate with hydrocortisone sodium succinate (Solu-Cortef).

2. Administer lorazepam (Ativan) before the procedure. An individual 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.

When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? 1.Increased serum albumin 2.Decreased respiratory compliance 3.Increased gastrointestinal (GI) motility 4.Decreased blood urea nitrogen (BUN)/creatinine ratio

2. Decreased respiratory compliance Clinical 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 would recognize which clinical manifestation as suggestive of sepsis? 1.Sudden diuresis unrelated to drug therapy 2.Hyperglycemia in the absence of diabetes 3.Respiratory rate of seven breaths per minute 4.Bradycardia with sudden increase in blood pressure

2. Hyperglycemia in the absence of diabetes 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.

A 64-yr-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 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 physician order should the nurse complete first? 1.Obtain a 12-lead ECG and arterial blood gases. 2.Rapidly administer 1000 mL normal saline solution IV. 3.Administer norepinephrine (Levophed) by continuous IV infusion. 4.Carefully insert a nasogastric tube and an indwelling bladder catheter.

2. Rapidly administer 1000 mL normal saline solution IV. 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 initiated after fluid resuscitation is initiated.

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68 mm Hg. The nurse minimally suspects which stage of shock based on this data? 1.Stage 1 2.Stage 2 3.Stage 3 4.Stage 4

2. Stage 2 Shock is categorized by 4 stages. Stage 1 is characterized by restlessness, increased heart rate, cool and pale skin, and agitation. Stage 2 is characterized by a cardiac output that is less than 4 to 6 liters per minute, systolic blood pressure less than 100 mm Hg. Stage 3 is characterized by edema, excessively low blood pressure, dysrhythmias, and weak and thready pulses. Stage 4 is characterized as unresponsiveness to vasopressors, profound hypotension, slowed heart rate, and multiple organ failure. Most often, the client will not survive.

The nurse is caring for a 29-yr-old man who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The attending physician 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? 1.Antibiotics are not useful when an infection has progressed to sepsis. 2.Weaning the patient away from the ventilator is the top priority in sepsis. 3.Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. 4.The patient has recovered from sepsis if he has warm skin and ruddy cheeks.

3. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. 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.

A patient's localized infection has become systemic and septic shock is suspected. What medication is expected to treat septic shock refractory to fluids? 1.Insulin infusion 2.Furosemide (Lasix) IV push 3.Norepinephrine administered by titration 4.Administration of nitrates and β-adrenergic blockers

3. Norepinephrine administered by titration 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 administered to normalize blood sugar and improve overall outcomes, but it is not considered a medication used to treat shock.

The nurse is caring for a 72-yr-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be most concerning? 1. Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds 2. Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin 3. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding 4.Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL

3. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding Severe hypoxemia, lactic acidosis, and bleeding are clinical 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 clinical 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 clinical manifestations of the progressive stage of shock.

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)? 1.A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture 2.A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia 3.A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina 4.A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection

4. A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection 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. Individuals 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.

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1.CO 5 L/min, PCWP low 2.CO 3 L/min, PCWP low 3.CO 4 L/min, PCWP high 4.CO 3 L/min, PCWP high

4. CO 3 L/min, PCWP high The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure.

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? 1.Heparin overdose 2.Vitamin K deficiency 3.Factor VIII deficiency 4.Disseminated intravascular coagulopathy (DIC)

4. Disseminated intravascular coagulopathy (DIC) TSS is caused by infection and often is associated with tampon use. The client's clinical signs in this question are compatible with DIC, which is a complication of TSS. The nurse assesses the client at risk and notifies the primary health care provider promptly when signs and symptoms of DIC are noted. Although signs of bleeding may be seen with each of the conditions listed in the incorrect options, the initial diagnosis of TSS makes DIC the logical correct option

What laboratory finding is consistent with a medical diagnosis of cardiogenic shock? 1.Decreased liver enzymes 2.Increased white blood cells 3.Decreased red blood cells, hemoglobin, and hematocrit 4.Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels

4. Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels 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.

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? 1.Acute pain 2.Impaired skin integrity 3.Decreased cardiac output 4.Ineffective tissue perfusion

4. Ineffective tissue perfusion 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.

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? 1.Cardiac index (CI) of 5 L/min/m2 2.Central venous pressure of 8 mm Hg 3.Mean arterial pressure (MAP) of 86 mm Hg 4.Pulmonary artery pressure (PAP) of 28/14 mm Hg

4. Pulmonary artery pressure (PAP) of 28/14 mm Hg 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. The normal range for PAP is 15 - 25 / 5-15 mmHg.

If the patient in shock is to receive 1000 mL of normal saline in 2 hours, at what rate should the infusion pump be set?_____________ mL per hour

500ml/hr For the 1000 mL of normal saline to be infused in 2 hours, the infusion pump should be set at 500 mL per hour (1000 mL divided by 2 hours).

Systemic Vascular Resistance (SVR) range

800-1200 dynes/sec/cm-5 - opposition to blood flow affecting left ventricular afterload - increase mean hypovolemic or cardiogenic shock - decrease indicates neurogenic, septic, or anaphylactic shock - vasopressor drugs increase SVR, improve perfusion and BP =((MAP-RAP)/CO) - 80

anaphylactic shock

A severe reaction that occurs when an allergen is introduced to the bloodstream of an allergic individual. S/S: bronchoconstriction, angioedema, labored breathing, wheezing, widespread vasodilation, increased cap. permeability, circulatory shock, and sometimes sudden death.

A patient's vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac output is 4.7 L/min. The patient's stroke volume is _____ mL. (Round to the nearest whole number.)

ANS: 52 Stroke volume = Cardiac output/heart rate 52 mL = (4.7 L x 1000 mL/L)/90 SV (normal is 60-100ml), low means cardiogenic shock

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 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. Give vancomycin 1 g IV. b. Obtain blood and urine cultures c. Start norepinephrine 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation above 95%.

ANS: E, D, C, B, A e. Titrate oxygen administration to keep O2 saturation above 95%. d. Infuse normal saline 2000 mL over 30 minutes. c. Start norepinephrine 0.5 mcg/min. b. Obtain blood and urine cultures a. Give vancomycin 1 g IV. The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures obtained before giving antibiotics.

The nurse is caring for a patient who has an intraaortic balloon pump (IABP) after a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Confirm that the IABP console has turned off. b. Assess the patient's vital signs and orientation. c. Obtain supplies for insertion of a new IABP catheter. d. Notify the health care provider of the IABP malfunction.

ANS: a. Confirm that the IABP console has turned off. b. Assess the patient's vital signs and orientation. d. Notify the health care provider of the IABP malfunction. c. Obtain supplies for insertion of a new IABP catheter. Blood in the IABP catheter indicates a possible tear in the balloon. The console should shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patient's assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed based on the patient assessment and the decision of the health care provider.

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. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

ANS: A, B, C, D a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. 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 given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS

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 Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

ANS: A, B, D, E a. Prepare to administer atropine IV. b. Obtain baseline body temperature. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation. All of the actions are appropriate except to give large volumes of lactated Ringer's 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 Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.

ANS: A. Administer furosemide (Lasix) 40 mg IV. Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock require large amounts of fluid replacement. If the patient remains hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.

When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do? a. Discontinue the catheter and culture the tip. b. Use the catheter only for fluid administration. c. Change the flush system and monitor the site. d. Check the site more frequently for any swelling.

ANS: A. Discontinue the catheter and culture the tip. The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued to avoid further complications such as endocarditis. Changing the flush system, continued monitoring, or using the line for fluids will not help prevent or treat the infection.

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. Give epinephrine. b. Administer diphenhydramine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count (CBC)

ANS: A. Give epinephrine. 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 septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 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 to keep systolic blood pressure above 90 mm Hg.

ANS: A. Give normal saline IV at 500 mL/hr. Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

ANS: A. Increase in the patient's heart rate Atropine will increase the heart rate and conduction through the AV node. Because the drug increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

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 c. Heart rate 112 beats/min b. Decreased bowel sounds d. Pale, cool, and dry extremities

ANS: A. New onset of confusion 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

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. Skin cool and clammy c. Blood pressure of 92/56 mm Hg b. Heart rate of 118 beats/min d. O2 saturation of 93% on room air

ANS: A. Skin cool and clammy Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status.

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 patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

ANS: A. The patient's serum creatinine level is elevated. 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 symptoms consistent with the patient's diagnosis of cardiogenic shock.

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take action? a. The right hand feels cooler than the left hand. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The system is delivering 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 2 days previously.

ANS: A. The right hand feels cooler than the left hand. The change in temperature of the right hand suggests that blood flow to the right hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hr of flush solution.

One of the most frequent causes of hypovolemic shock in children is: a. Myocardial infarction. c. Anaphylaxis. b. Blood loss. d. Congenital heart disease.

ANS: B. Blood loss. Blood loss and extracellular fluid loss are two of the most frequent causes of hypovolemic shock in children. Myocardial infarction is rare in a child; if it occurred, the resulting shock would be cardiogenic, not hypovolemic. Anaphylaxis results in distributive shock from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease tends to contribute to hypervolemia, not hypovolemia

A 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 c. Cool, clammy extremities b. Heart rate 45 beats/min d. Temperature 101.2°F (38.4°C)

ANS: B. Heart rate 45 beats/min Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock

Which clinical changes occur as a result of septic shock? a. Hypothermia c. Vasoconstriction b. Increased cardiac output d. Angioneurotic edema

ANS: B. Increased cardiac output Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common in septic shock. Angioneurotic edema occurs as a manifestation in anaphylactic shock.

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

ANS: B. Infuse normal saline at 250 mL/hr. The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a. Avoid the use of anticoagulant medications. b. Measure the patient's urinary output every hour. c. Provide passive range of motion for all extremities. d. Position the patient supine with head flat at all times.

ANS: B. Measure the patient's urinary output every hour. Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.

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.

ANS: B. Monitor breath sounds frequently. Because 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

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

ANS: B. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome 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.

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. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

ANS: B. Provide O2 at 100% per non-rebreather mask. 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 O2 delivery have been implemented.

2. Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

ANS: B. Systemic vascular resistance (SVR) SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored but do not reflect afterload as directly

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's heart rate is 110 beats/minute.

ANS: B. The patient is complaining of chest pain. Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy.

Norepinephrine 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 patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since being admitted.

ANS: B. The patient's central venous pressure is 3 mm Hg. Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

ANS: B. Urine output is 65 mL over the past hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. 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.

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% albumin infusion c. epinephrine (Adrenalin) drip b. furosemide (Lasix) IV d. hydrocortisone (Solu-Cortef)

ANS: B. furosemide (Lasix) IV Elevated PAWP indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

Which clinical manifestations would the nurse expect to see as shock progresses in a child and becomes decompensated shock (Select all that apply)? a. Thirst and diminished urinary output b. Irritability and apprehension c. Cool extremities and decreased skin turgor d. Confusion and somnolence e. Normal blood pressure and narrowing pulse pressure f. Tachypnea and poor capillary refill time

ANS: C, D, F c. Cool extremities and decreased skin turgor d. Confusion and somnolence f. Tachypnea and poor capillary refill time Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock

A patient's heart monitor shows sinus rhythm, rate 64. The PR interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient. b. Give atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Call the health care provider before giving scheduled metoprolol (Lopressor). d. Document the patient's rhythm and assess the patient's response to the rhythm.

ANS: C. Call the health care provider before giving scheduled metoprolol (Lopressor). The patient has progressive first-degree atrioventricular (AV) block, and the b-blocker should be held until discussing the drug with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met? a. Urine output of 25 mL/hr b. Heart rate of 110 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat

ANS: C. Cardiac output (CO) of 5 L/min A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV (normal is 60-100ml) signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock

A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, what medication should the nurse prepare for immediate administration? a. Diphenhydramine (Benadryl) c. Epinephrine b. Dopamine d. Calcium chloride

ANS: C. Epinephrine After the first priority of establishing an airway, epinephrine is the drug of choice. Benadryl is not a strong enough antihistamine for this severe a reaction. Dopamine and calcium chloride are not appropriate drugs for this type of reaction.

The nurse is caring for a child after heart surgery. What should she or he do if evidence is found of cardiac tamponade? a. Increase analgesia. b. Apply warming blankets. c. Immediately report this to the physician. d. Encourage the child to cough, turn, and breathe deeply.

ANS: C. Immediately report this to the physician. If evidence is noted of cardiac tamponade (blood or fluid in the pericardial space constricting the heart), the physician is notified immediately of this life-threatening complication. Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred until after the evaluation by the physician

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

ANS: C. Increase the rate for the sodium nitroprusside infusion. 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

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. Maintaining a cool room temperature for a patient with neurogenic shock d. Increasing the nitroprusside infusion rate for a patient with a very high SVR

ANS: C. Maintaining a cool room temperature for a patient with neurogenic shock Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

ANS: C. The patient's IV infusion site is cool and pale. The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min 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

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No new heart murmurs c. Warm, pink, and dry skin b. Decreased troponin level d. Blood pressure of 92/40 mm Hg

ANS: C. Warm, pink, and dry skin Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. obtain the blood pressure. b. check the level of orientation. c. administer supplemental oxygen. d. obtain a 12-lead electrocardiogram.

ANS: C. administer supplemental oxygen. The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.

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. furosemide . c. norepinephrine . b. nitroglycerin . d. sodium nitroprusside .

ANS: C. norepinephrine When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

A patient reports dizziness and shortness of breath for several days. During heart monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).

ANS: C. third-degree atrioventricular (AV) block. The inconsistency between the atrial and ventricular rates and the variable PR interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent PR intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.

What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy? a. Neurogenic shock c. Hypovolemic shock b. Cardiogenic shock d. Anaphylactic shock

ANS: D. Anaphylactic shock Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure

Which nursing action is needed when preparing to assist with the insertion of a pulmonary artery catheter? a. Determine if the cardiac troponin level is elevated. b. Auscultate heart sounds before and during insertion. c. Place the patient on NPO status before the procedure. d. Attach cardiac monitoring leads before the procedure.

ANS: D. Attach cardiac monitoring leads before the procedure. Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate c. Blood pressure b. Orientation d. Oxygen saturation

ANS: D. Oxygen saturation Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device implanted. When planning care for this patient, the nurse should anticipate a. preparing the patient for a permanent VAD. b. administering immunosuppressive medications. c. teaching the patient the reason for complete bed rest. d. monitoring the surgical incision for signs of infection.

ANS: D. monitoring the surgical incision for signs of infection. The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices such as the VAD.

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain a. a dopamine infusion. c. lactated Ringer's solution. b. a hypothermia blanket. d. two 16-gauge IV catheters.

ANS: D. two 16-gauge IV catheters. 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 Ringer's 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.

is rapid IV resuscitation with two large bore IVs ok with cardiogenic shock

NO fluids will only worsen sitaution d/t pump failure

cardiac reserve

The ability of the heart to increase output in response to increased demand

Stroke Volume (SV)

The volume of blood ejected with each ventricular contraction - det. by afterload - normal is 60-150ml (low during shock) - SV = (Cardiac outputx1000)/heart rate

renin-angiotensin-aldosterone system (RAAS)

a hormone pathway that helps regulate blood pressure and blood volume retention of Na, increased stimulation of ADH (reabsorption of H2O from kidneys)

Cardiac Index (CI)

a measure of the cardiac output of a patient per square meter of body surface area. Normal range 2.5 to 4 L/min. < 2.1 inconsistent for weaning.

Ventricular assist device (VAD)

a mechanical pump that helps a weakened ventricle to pump blood throughout the body -improves heart fn +blood flow - not permanent, source of infection - for patients in need of a transplant - decreases SVR

neurogenic shock

a state of shock (hypoperfusion) caused by nerve paralysis that sometimes develops from spinal cord injuries, hypovolemia - loss of vasomotor tone and SNS control below injury - s/s: hypotension, bradycardia, poikilothermia - tx: airway support, IV fluids (LR), atropine (bradycardia), vasopressors (increase BP)

uncorrected hypovolemic shock leads to

acidosis leads to multi system organ failure and death

Absolute hypovolemia

actual loss of intravascular fluid volume from body *hemorrhage, VD, fistula drainage, diabetes insipidus, diuresis*

what are red flags for cerebral hypoxia

anxiety + decreased LOC

Intraortic Balloon Pump (IABP)

balloon catheter placed percutaneously via femoral artery into the aorta near the L subcalvian artery

If blood loss continues to occur what happens

blood is shunted away from non-vital organs + tissues *maintain perfusion to heart + brain*

hypovolemic shock is the most common type of shock in who

children with blood loss or reduced vascular fluid volume

peripheral hypoperfusion causes what

cyanosis pallor diaphoresis weal periph. pulses cool, clammy skin delayed cap. refill

Relative hypovolemia

displacement of fluid from vascular space to interstitial space *third spacing i.e. ascites*

what drug is given emergently for anaphylactic shock

epinephrine -causes vasoconstriction -decreases bronchospasm (bronchodilates) -blocks histamine

clinical manifestations in septic shock

fever/chills hypotension (systolic <90) vasodilation increased CO oliguria (hypernatremia) confusion tachycardia pallor fatigue SOB sweating N/V

angioedema

fluid leaking into interstitial space -swelling of face + larynx

systolic dysfunction

inability of the heart to pump blood to the vasculature, this causes a weakened LV

cellular hypoxia

inadequate oxygen in the cells causes metabolic waste accumulation

Circulatory Assist Devices (CADs)

mechanical devices used to maintain vital organ perfusion and improve CO by reducing cardiac filling pressures, decreases LV volume and assist coronary perfusion

Pulmonary Vascular Resistance (PVR)

opposition to blood flow affecting *RV* <250 dynes/sec/cm-5, increase indicates shock

Mean Arterial Pressure (MAP)

pressure that propels blood to tissues MAP = diastolic pressure + 1/3 pulse pressure 70-105 mmHg

decreased renal perfusion activates the

renin-angiotension-aldosterone system (RAAS)

what happens when the body is in a state of O2 deprivation

switch to anaerobic metabolism and lactic acid is produced

septic shock

syndrome of life threatening organ dysfunction caused by dysregulated response to infection - s/s: Tachycardia, increased CO, fever, hypotension (SYSTOLIC <90), pallor, fatigued, cold, reduced urine output, SOB, Decreased LOC,N/V, sweating, vasodilation, hyperglycemia - tx: Blood cultures, aggressive fluid resuscitation, vasopressors: levophed, dopamine, dobutamine; abx within 1 hour - requires ventilation, blankets to conserve heat

the SNS causes

tachycardia (to improve CO) tachypnea (to improve oxygenation) decreased U/O (to preserve intravasc. vol)

hemodynamic monitoring

the use of pressure monitoring devices to directly measure cardiovascular function

preload

volume at end of diastole, just prior to contraction

respiratory arrest

when breathing completely stops laryngeal edema + bronchospasm

vasodilation

widening of blood vessels causes hypotension severe hypoperfusion