maya questions #2
A client has blood loss following an automobile accident. The blood pressure on admission to the emergency department is 80/40 mm Hg. What is the primary goal for the care of the client at this time? A Preserve renal function. B Prevent hypostatic pneumonia. C Achieve adequate tissue perfusion. D Maintain adequate vascular tone.
Correct Answer: Achieve adequate tissue perfusion. Explanation: A primary outcome for the care of the client in shock is to achieve adequate tissue perfusion, thus avoiding multiple organ dysfunction. The lungs are susceptible to injury, especially acute respiratory distress syndrome. Vasoconstriction occurs as a compensatory mechanism until the client enters the irreversible stage of shock.
A child with 20% second- and third-degree burns is admitted to the burn center. The child weighs 44 lbs (20 kg). The nurse has started an IV infusion of lactated Ringer solution and inserted an indwelling catheter. Which of the findings indicate that the child is going into shock? Select all that apply. A Urinary output is 25 mL/h. B Pain is 7 on a pain scale of 1 to 10. C Blood pressure is dropping. D Heart rate is elevated. E Specific gravity is within normal limits.
Correct Answers Blood pressure is dropping. Heart rate is elevated. Explanation: The child is observed for shock that can occur following a severe burn. Shock is noted by the increasing heart rate and dropping blood pressure. This child has an adequate urine output (more than 1 mL/kg body weight), and the specific gravity is within normal range. Pain is expected and is not an indicator of shock.
A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: international normalized ratio (INR), 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). In which order, from first to last, should the nurse implement the health care provider's prescriptions? All options must be used. 1. Give 1 unit fresh frozen plasma (FFP). 2. Administer vitamin K 2.5 mg by mouth. 3. Schedule the client for sigmoidoscopy. 4. Administer IV dextrose 5% in 0.45% normal saline.
4 1 2 3 4123 4, 1, 2, 3 Explanation: Analysis of the client's laboratory results indicates that an INR of 8 is increased beyond therapeutic ranges. The client is also experiencing severe acute rectal bleeding and has a hemoglobin level in the low range of normal and a hematocrit reflecting fluid volume loss. The nurse should first establish an IV line and administer the dextrose in saline. Next, the nurse should administer the FFP. FFP contains concentrated clotting factors and provides an immediate reversal of the prolonged INR. Vitamin K 2.5 mg PO should be given next because it reverses the warfarin by returning the PT to normal values. However, the reversal process occurs over 1 to 2 hours. Lastly, the nurse can schedule the client for the sigmoidoscopy.
A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is: A a blood clot that formed in the kidneys." B structural damage to the kidney." C a decrease in the blood flow through the kidneys." D an obstruction of urine flow from the kidneys."
Correct Answer: a decrease in the blood flow through the kidneys." Explanation: There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.
Which clients should the nurse monitor closely for manifestations of multiple organ dysfunction syndrome (MODS)? Select all that apply. A ARDS B GI Bleed C Sepsis D DKA E Head trauma
Correct Answers Client with acute respiratory failure Client with a gastrointestinal bleed Client with sepsis Explanation: Infection (such as sepsis) is the most common cause of multiple organ dysfunction syndrome (MODS). Hemorrhage and respiratory failure are other causes. Primary MODS is believed to be the result of inadequate oxygen delivery to cells and a failure of the microcirculation to remove metabolic end products as seen with hypoxemia or hemorrhage. Head trauma and diabetic ketoacidosis do not place a client at risk for MODS.
The nurse has just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention? A A 45-year-old client with partial-thickness leg burns who has a temperature of 102.6°F (39.2°C) and a blood pressure of 98/46 mm Hg B A 22-year-old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left C A 57-year-old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L (5.1 mmol/L) D A 34-year-old client who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0 to 10)
Correct Answer: A 45-year-old client with partial-thickness leg burns who has a temperature of 102.6°F (39.2°C) and a blood pressure of 98/46 mm Hg Explanation: This client's vital signs indicate that the life-threatening complications of sepsis and septic shock may be developing. The other clients also need rapid assessment or nursing interventions, but their symptoms do not indicate that they need care as urgently as the febrile and hypotensive client. Focus: Prioritization; Test Taking Tip: Remember that when skin integrity is affected due to large burn injuries, clients are at high risk for complications such as sepsis and hypovolemia. You should monitor for changes in vital signs that might indicate these complications are occurring.
There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital? A A middle-aged female with cold, clammy skin, heart rate of 120 bpm, and is unconscious B A 10-year-old with a simple fracture of the femur, who is crying and cannot find his parents C An older adult with severe headache, but conscious D A middle-aged male with severe asthmas, heart rate of 120 bpm, and is having difficulty breathing
Correct Answer: A middle-aged female with cold, clammy skin, heart rate of 120 bpm, and is unconscious Explanation: The middle-aged female is likely in shock; she is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III, urgent, and can be treated within 30 minutes. The man with asthma and the man with the severe headache are classified as emergent, triage level II, and can be transported by ambulance and reach the hospital within 15 minutes.
Which finding is an indication of a complication of septic shock? A Anaphylaxis B Chronic obstructive pulmonary disease (COPD) C Acute respiratory distress syndrome (ARDS) D Mitral valve prolapse
Correct Answer: Acute respiratory distress syndrome (ARDS) Explanation: ARDS is a complication associated with septic shock. ARDS causes respiratory failure and may lead to death, even after the client has recovered from shock. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial airflow and involves chronic bronchitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.
A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are as follows: heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0°F (36.1°C); and oxygen saturation 89% on room air. Which prescription should the nurse implement first? A Insert an indwelling urinary catheter. B Obtain an abdominal X-ray. C Draw a complete blood count with hematocrit and hemoglobin. D Administer 1 L 0.9% normal saline IV.
Correct Answer: Administer 1 L 0.9% normal saline IV. Explanation: The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (e.g., 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which prescription from the health care provider should the nurse verify before implementing? A Administer metoprolol 5 mg IV push. B Prepare for a pulmonary artery catheter insertion. C Titrate dobutamine to keep systolic blood pressure >100 mm Hg. D Call for urine output <30 mL/h for 2 consecutive hours.
Correct Answer: Administer metoprolol 5 mg IV push. Explanation: Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability, and a beta-blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? A Fluid balance B Altered level of consciousness C Anaphylactic reaction D Pain
Correct Answer: Anaphylactic reaction Explanation: The client who is receiving a blood product requires astute assessment for signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction occurs, the nurse should stop the transfusion immediately, but leave the IV line intact, and notify the health care provider (HCP) . Usually, an antihistamine (such as diphenhydramine hydrochloride) is administered. Epinephrine and corticosteroids may be administered in severe reactions. Fluid balance is not an immediate concern during the blood administration. The administration should not cause pain unless it is extravasating out of the vein, in which case the IV administration should be stopped. Administration of a unit of blood should not affect the level of consciousness.
The nurse is assessing a client with irreversible shock. The nurse should document the progression of which expected finding? A Hypertension B Circulatory collapse C Increased alertness D Diuresis
Correct Answer: Circulatory collapse Explanation: Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert.
The nurse is assessing a client who is in shock. Which neurologic change indicates that the client is in the progressive stage of shock? A Confusion B Restlessness C Incoherent speech D Unconsciousness
Correct Answer: Confusion Explanation: In the progressive stage of shock, the client can display listlessness or agitation, confusion, and slowed speech. Restlessness occurs in the compensatory stage. Incoherent speech and unconsciousness are clinical manifestations of the irreversible stage
Which finding is a risk factor for hypovolemic shock? A Vasodilation B Antigen-antibody reaction C Gram-negative bacteria D Hemorrhage
Correct Answer: Hemorrhage Explanation: Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock.
The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? A Hypovolemic B Neurogenic C Cardiogenic D Anaphylactic
Correct Answer: Hypovolemic Explanation: A fractured femur, especially an open fracture, can cause much soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop. Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous system function. Anaphylactic shock is the result of an allergic reaction.
The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? A Oxygen at 3 L via nasal cannula B IV 5% dextrose in water to run at 250 mL/hr C Blood pressure every 15 minutes D Place two 18-gauge IV lines
Correct Answer: IV 5% dextrose in water to run at 250 mL/hr Explanation: To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic. All of the other interventions are appropriate for a client with shock.
The client who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the desired effect, what should the nurse assess? A Increased renal and mesenteric blood flow B Reduced preload and afterload C Increased cardiac output D Vasoconstriction
Correct Answer: Increased cardiac output Explanation: At medium doses (4 to 8 mcg/kg/min), dopamine hydrochloride slightly increases the heart rate and improves contractility to increase cardiac output and improve tissue perfusion. When given at low doses (0.5 to 3.0 mcg/kg/min), dopamine increases renal and mesenteric blood flow. At high doses (8 to 10 mcg/kg/min), dopamine produces vasoconstriction, which is an undesirable effect. Dopamine is not given to affect preload and afterload.
A nurse is assessing a client with lymphoma who reports distress 9 days after chemotherapy. Because of the risk for septic shock, the nurse should assess the client for which cluster of symptoms? A Elevated temperature, oliguria, hypotension B Low-grade fever, chills, tachycardia C Flushing, decreased oxygen saturation, mild hypotension D High-grade fever, normal blood pressure, increased respirations
Correct Answer: Low-grade fever, chills, tachycardia Explanation: Nine days after chemotherapy, it is expected for the client to be immunocompromised. The clinical signs and symptoms of shock reflect changes in cardiac function, vascular resistance, cellular metabolism, and capillary permeability. Low-grade fever, tachycardia, and chills may be early signs of shock. The client with signs and symptoms of impending septic shock may not have decreased oxygen saturation levels. Oliguria and hypotension are late signs of shock. Urine output can be initially normal or increased.
Which nursing intervention is most important in preventing septic shock? A Maintaining asepsis of indwelling urinary catheters B Administering IV fluid replacement therapy as prescribed C Monitoring red blood cell counts for elevation D Obtaining vital signs every 4 hours for all clients
Correct Answer: Maintaining asepsis of indwelling urinary catheters Explanation: Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.
What is the most important goal of nursing care for a client who is in shock? A Manage vasoconstriction of vascular beds. B Manage increased cardiac output. C Manage inadequate tissue perfusion. D Manage fluid overload.
Correct Answer: Manage inadequate tissue perfusion. Explanation: Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.
A client is receiving dopamine hydrochloride for treatment of shock. What action should the nurse take? A Monitor for signs of infection. B Monitor blood pressure continuously. C Evaluate arterial blood gases at least every 2 hours. D Administer pain medication concurrently.
Correct Answer: Monitor blood pressure continuously. Explanation: The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine hydrochloride.
A nurse is assessing a client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg, and on admission to the postsurgical nursing unit it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. After determining that other vital signs are normal, what should the nurse do first? A Notify the health care provider. B Elevate the head of the bed. C Call the rapid response team. D Administer pain medication.
Correct Answer: Notify the health care provider. Explanation: The client's systolic blood pressure is dropping, and the pulse pressure is narrowing, indicating impending shock. The nurse should immediately notify the HCP . Elevating the head of the bed will not increase the blood pressure. Administering pain medication could cause the blood pressure to drop further. It is not necessary to activate the rapid response team unless the client's vital signs change before the HCP evaluates the client.
When emptying the client's bladder during a urinary catheterization, the nurse should allow the urine to drain from the bladder slowly to prevent which complication? A Atrophy of bladder musculature B Possible shock C Abdominal cramping D Renal failure
Correct Answer: Possible shock Explanation: Rapid emptying of an overdistended bladder may cause hypotension and shock due to the sudden change of pressure within the abdominal viscera. The nurse should empty the bladder slowly. Removal of urine from the bladder does not cause renal failure. The client may experience cramping, but the primary concern is the potential for shock. Bladder muscles will not atrophy because of a catheterization.
A client with toxic shock has been receiving ceftriaxone sodium, 1 g every 12 hours. In addition to culture and sensitivity studies, what other laboratory finding should the nurse monitor? A Serum creatinine B Arterial blood gases C Serum osmolality D Spinal fluid analysis
Correct Answer: Serum creatinine Explanation: The nurse monitors the blood levels of antibiotics, white blood cells, serum creatinine, and blood urea nitrogen because of the decreased perfusion to the kidneys, which are responsible for filtering out the ceftriaxone sodium. It is possible that the clearance of the antibiotic has been decreased enough to cause toxicity. Increased levels of these laboratory values should be reported to the health care provider (HCP) immediately. A spinal fluid analysis is done to examine cerebral spinal fluid, but there is no indication of central nervous system involvement in this case. Arterial blood gases are used to determine actual blood gas levels and assess acid-base balance. Serum osmolality is used to monitor fluid and electrolyte balance.
The client is admitted to the emergency department with an apical pulse rate of 134, respiration rate of 28, BP of 92/56, and the skin is pale and clammy. What action should the nurse perform first? A Check the client's allergies to medications. B Start two IVs with large-bore catheters. C Type and crossmatch the client for PRBCs. D Obtain the client's history and physical.
Correct Answer: Start two IVs with large-bore catheters. Explanation: The client is exhibiting symptoms of shock. The nurse should start IV lines to prevent the client from progressing to circulatory collapse. The nurse should first prevent circulatory collapse by starting two IVs and initiating normal saline or Ringer's lactate. The crossmatch may be needed if the shock condition is caused by hemorrhage. All clients have a history taken and physical examination performed as part of the admission process to the emergency department, but this is not the first intervention. Checking the client's allergies to medications is important, but it is not the first intervention in a client exhibiting signs of shock.
Which finding indicates hypovolemic shock in an adult who has had a 15% blood loss? A Pupils unequally dilated B Pulse rate <60 bpm C Respiratory rate of 4 breaths/min D Systolic blood pressure <90 mm Hg
Correct Answer: Systolic blood pressure <90 mm Hg Explanation: Typical signs and symptoms of hypovolemic shock include systolic blood pressure <90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.
The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which changes noted from the client's chart to the health care provider? A Heart rate B Urine output C Respiratory rate D Blood pressure
Correct Answer: Urine output Explanation: Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client's chart are not as significant as the decreased urinary output.
Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate? A Respiratory rate of 20 breaths/min B Diastolic blood pressure >90 mm Hg C Systolic blood pressure >110 mm Hg D Urine output >30 mL/h
Correct Answer: Urine output >30 mL/h Explanation: Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently >35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock. OK
When assessing a client for early septic shock, the nurse should assess the client for which finding? A Hemorrhage B Warm, flushed skin C Cool, clammy skin D Increased blood pressure
Correct Answer: Warm, flushed skin Explanation: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.