Chapter 14: Shock/Sepsis
The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a patient with septicemia. Which intervention will address this patient's health problem? 1) Monitor for cyanosis. 2) Monitor heart rate every hour. 3) Assess temperature every four hours. 4) Monitor pupil reactions every eight hours.
ANS: 1 A change in skin color will alert the nurse immediately of decreased tissue perfusion.
The nurse is administering albumin 5% to a patient in shock. Which nursing action is appropriate when assessing this patient? 1) Auscultate breath sounds for crackles 2) Auscultate breath sounds for hyperresonance 3) Auscultate breath sounds for inspiratory stridor 4) Auscultate for an absence of breath sounds in the lower lobes
ANS: 1 Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion
A nurse is caring for a patient who was involved in a motor vehicle accident who has lost approximately 1,500 mL of blood. Based on this data, which type of shock is the patient experiencing? 1) Hypovolemic 2) Cardiogenic 3) Distributive 4) Obstructive
ANS: 1 Blood loss causes hypovolemic shock.
The nurse explains the purpose of an infusion of albumin 5% to a patient recovering from hypovolemic shock. Which statement indicates that the patient understands the instructions? 1) "It is a protein that pulls water into my blood vessels." 2) "It is a protein that causes my kidneys to conserve fluid." 3) "It is a super-concentrated salt solution that helps me conserve body fluid." 4) "It is a liquid that has electrolytes in it to pull water into my blood vessels."
ANS: 1 Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure.
An older adult patient is recovering in the intensive care unit (ICU) from septicemia. Which intervention will help prevent further infection for this patient? 1) Provide oral and skin care 2) Implement sterile wound care 3) Encourage turn, cough, and deep breathe every shift. 4) Place the Foley drainage on the bed at the patient's feet
ANS: 1 Good oral and skin care will prevent breakdown and prevent entry by bacteria.
The nurse is preparing an educational session on sepsis. Which should the nurse include as a major risk factor for the development of this health problem? 1) Immunosuppression 2) Elevated temperature 3) Pneumococcal bacteria 4) Leukocytosis on the complete blood count
ANS: 1 Immunosuppression is a risk factor for the development of sepsis.
A patient is prescribed epinephrine for the prevention of anaphylactic shock. The patient states, "I thought shock was about heart failure." Which response by the nurse is most appropriate? 1) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." 2) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." 3) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure." 4) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure."
ANS: 1 Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest anaphylactic shock.
A patient in neurogenic shock is receiving rapid intravenous fluids. Which assessment finding indicates the need for additional nursing interventions? 1) The patient's mean arterial pressure (MAP) is 60 mmHg. 2) The patient is unconscious. 3) The patient has received two liters of infused fluid. 4) The patient is perspiring heavily.
ANS: 1 The MAP should be at least 65 mmHg. This finding indicates the need for further intervention.
A patient is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this patient for when administering the infusion? Select all that apply. 1) Confusion 2) Tachycardia 3) Disorientation 4) Muscle spasms 5) Gastrointestinal bleeding
ANS: 1, 2, 3 1. This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the health-care provider.
A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with late septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. 1) Shallow respirations 2) Lethargic mental status 3) Decreased urine output 4) Normal blood pressure 5) Warm and flushed skin 6) Rapid and deep respirations
ANS: 1, 2, 3 This is correct. Late-phase manifestations include shallow respirations, lethargic mental status, and decreased urine output.
Which will the nurse closely monitor due to the pathophysiology associated with early shock? Select all that apply. 1) Bowel sounds 2) Level of consciousness 3) Urine output 4) Peripheral pulses 5) Heart rate
ANS: 1, 3, 4 1. This is correct. Compensatory changes in early shock can result in hypoperfusion of the gut; therefore, the nurse must closely assess bowel sounds. 3. This is correct. The shunting that occurs in early shock may cause hypoperfusion of the kidneys leading to decreased urine output; therefore, the nurse must closely monitor intake versus output. 4. This is correct. The body shunts blood away from the peripheral tissues in an effort to keep vital organs perfused; therefore, the nurse will monitor for decreased peripheral pulses when assessing for early clinical manifestations of shock.
Which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock? Select all that apply. 1) Pallor 2) Increased bowel sounds 3) Restlessness 4) Decreased blood glucose 5) Increased respiratory rate
ANS: 1, 3, 5 1. This is correct. Pallor of the skin, lips, oral mucosa, nail beds, and conjunctiva may occur in early shock. 3. This is correct. Slight decreases in perfusion of the brain may result in restlessness. 5. This is correct. A compensatory mechanism for decreased tissue oxygenation is the attempt to obtain additional oxygen through more rapid respirations.
The nurse is preparing to administer diphenhydramine to a patient who is experiencing a severe allergic reaction to peanuts. Which information about the drug should the nurse provide to the patient? 1) "This is the medication of choice to treat airway obstruction." 2) "This medication will help relieve your itching and runny nose." 3) "This medication will prevent you from going into anaphylactic shock." 4) "This medication will take a while to be effective but will control your symptoms for several hours."
ANS: 2 Antihistamines help to relieve histamine-related symptoms such as itching, flushing, hives, and rhinorrhea.
The nurse is providing care to a patient who is admitted with cardiogenic shock. The nurse administers the prescribed atropine with no results. Which prescription does the nurse anticipate from the health-care provider based on this data? 1) A beta blocker 2) Transcutaneous pacing 3) Cardiac defibrillation 4) A preload reducer
ANS: 2 Atropine is administered as treatment for bradycardia that can occur as a result of cardiogenic shock. If the patient is not responsive to atropine, pacing is likely necessary.
Which is the highest priority nursing action when providing care to a patient with shock? 1) Starting two large intravenous catheters 2) Recognizing early clinical manifestations 3) Administering high-flow oxygen 4) Calling for help immediately
ANS: 2 Early recognition of the clinical manifestations of shock can save the patient's life and is the priority action.
A nurse working in the intensive care unit (ICU) is caring for a patient in refractory stage of shock. When planning care, which does the nurse anticipate? 1) A subtle change in heart rate 2) A change from aerobic to anaerobic metabolism 3) The development of hyperglycemia 4) The development of cardiac dysrhythmias
ANS: 2 In the refractory stage of shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion.
The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic, hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient? 1) Starting two large intravenous catheters 2) Notifying the Rapid Response Team 3) Calling the patient's physician to report the changes 4) Placing oxygen on the patient
ANS: 2 The nurse should call for help from the Rapid Response Team.
A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with early septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. 1) Shallow respirations 2) Normal blood pressure 3) Warm and flushed skin 4) Lethargic mental status 5) Decreased urine output 6) Rapid and deep respirations
ANS: 2, 3, 6 This is correct. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin.
A patient is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this patient? Select all that apply. 1) Pain 2) Fever 3) Edema 4) Anorexia 5) Tachycardia
ANS: 2, 4, 5 This is correct. Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection.
A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the nurse anticipate for this patient? 1) Increased cardiac output 2) Stabilization of fluid loss 3) Urinary output of at least 30 mL/hour 4) Vasoconstriction and increased blood pressure
ANS: 3 At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading to vasodilation and an increased blood flow through the kidneys
The nurse is providing care to a patient who is admitted to the emergency department with symptoms of a myocardial infarction (MI). Which is the primary purpose of the interventions administered to this patient? 1) Providing pain relief 2) Preventing extension of damage 3) Preventing cardiogenic shock 4) Reducing blood pressure
ANS: 3 Cardiogenic shock is the cause of death for many persons who have a myocardial infarction. Interventions are designed to reduce the risk of cardiogenic shock when treating a patient experiencing an MI.
A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most appropriate? 1) Starting an 18-gauge intravenous catheter in the patient's nondominant hand 2) Ordering a type and cross-match of packed red blood cells 3) Preparing to assist with central line placement 4) Inserting a nasogastric tube
ANS: 3 Rapid volume expansion requires the use of large veins, preferably a central line.
The nurse is providing care to a patient admitted to the emergency department (ED) with a gunshot wound and profound blood loss. Which order does the nurse anticipate for this patient? 1) Normal saline 2) Dextrose in water 3) Packed red blood cells 4) Albumin
ANS: 3 Replacement of lost fluid with packed red blood cells increases oxygen-carrying capacity. This is the best choice for blood loss from trauma such as gunshot wounds.
The nurse has just completed the assessment of a patient admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this patient? 1) Ineffective Coping 2) Deficient Fluid Volume 3) Decreased Cardiac Output 4) Ineffective Airway Clearance
ANS: 3 The patient sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the patient is Decreased Cardiac Output because of low blood volume.
The nurse is providing care for a patient receiving treatment for cardiogenic shock. Which assessment finding indicates that the compensatory mechanism of vasoconstriction has occurred in this patient? 1) Increased heart rate 2) Increased injection fraction 3) Decreased urine output 4) Decreased temperature
ANS: 3 Vasoconstriction results in diminished renal blood flow and urine production.
An older adult patient is experiencing hypovolemic shock. Which is the priority intervention for this patient? 1) Assessing the cause of bleeding 2) Providing replacement of volume 3) Establishing invasive cardiac monitoring 4) Administering analgesics for control of pain
ANS: 3 With aging, there is a decrease in cardiac sympathetic activity. Older patients can have secondary volume depletion because of diuretics or malnutrition, and if prescribed a beta blocker, tachycardia may not occur as an early sign of hypovolemic shock. The older patient will require early invasive monitoring in order to avoid excessive or inadequate volume restoration. This should be done early in the treatment phase
The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment findings support the nurse's concern? Select all that apply. 1) Rapid weak pulse 2) Normal respirations 3) Normal blood pressure 4) Slight increase in pulse 5) Prolonged capillary refill time
ANS: 3, 4, 5 This is correct. Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations, prolonged capillary refill time, and normal blood pressure
During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing the patient? 1) Lethargy 2) Hypotension 3) Respiratory alkalosis 4) Subtle changes in heart rate
ANS: 4 Subtle or no clinical manifestations are anticipated when providing care to a patient in the initial stage of shock.
The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is appropriate for this patient during the initial compensatory phase? 1) Placing a cool blanket over the patient 2) Raising the patient's head to a 30-degree angle 3) Positioning the patient in the left-lateral recumbent position 4) Turning the patient's head to one side if no neck injury is suspected
ANS: 4 Turing the patient's head to one side protects the airway in case of vomiting.
The nurse is conducting medication teaching for a patient who is prescribed an epi-pen. Which statements made by the patient indicates the need for additional instruction? 1) "I will carry an epi-pen with me at all times." 2) "I will check the expiration date on my epi-pen regularly." 3) "I should hold the epi-pen in place for 10 seconds after injection." 4) "I should use the epi-pen to inject the drug into my abdominal wall."
Ans 4 The pen is placed against the thigh, not the abdomen, for injection. This statement indicates the need for additional instruction
