med surg chp. 34 quiz

How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? A. Lactate 81 mg/dL (9.0 mmol/L) B. Partial thromboplastin time 64 seconds C. Potassium 2.8 mEq/L (2.8 mmol/L) D. PaCO2 58 mm Hg

ans: A rationale: The client with septic shock and a lactate level of 81 mg/dL (0.9 mmoL/L) indicates that severe tissue hypoxia is present. Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid.Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis, but this value is decreased and is not consistent with septic shock.

The assistive personnel (AP) is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What is the appropriate nursing action? A. Compare these vital signs with the last several readings. B. Increase the rate of intravenous fluids. C. Request that the surgeon see the client. D. Reassess vital signs using different equipment.

ans: A rationale: The nurse will take the vital sign trends into consideration. A BP of 90/60 mm Hg may be normal for this client.Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment must be used when vital signs are taken postoperatively.

The nurse is caring for a patient in the initial stage of hypovolemic shock. What assessment data will the nurse anticipate? A. Heart rate 118 B. 2+ pedal pulses C. Bilateral fine crackles in lung bases D. BP change from 100/60 to 100/40

ans: A rationale: With the initial stage of shock, an increase is heart rate is often the first indicator. Because stroke volume is decreased the pedal pulses are often difficult to palpate and easily blocked. A normal pedal pulse (2+) would not be anticipate. The nurse would not anticipate bilateral fine crackles in the lungs with hypovolemic shock. The nurse would anticipate a narrow pulse pressure change (versus a widened pulse pressure). With vasoconstriction, diastolic pressure increases, but systolic pressure remains the same. This creates a narrow pulse pressure.

A client in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which signs will the nurse attribute to ongoing compensatory mechanisms? Select all that apply. A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output

ans: A, B, D, E, H rationale: Compensatory mechanisms attempt to maintain perfusion and gas exchange to vital organs. Thus these mechanisms shunt blood away from less vital organs and try to prevent further volume losses. The increasing pallor occurs because blood is shunted away from skin and mucous membranes to the heart, brain, liver, and lungs. Increasing thirst and decreasing urine output help to increase blood volume by stimulating the patient to drink and by preventing fluid loss through the urine. Increasing heart rate and respiratory rate work to maintain gas exchange to those selected organs that continue to be perfused. Increasing confusion indicates the compensatory mechanisms are failing and that the brain is not being adequately perfused. Decreasing systolic blood pressure also is an indication of worsening shock. Decreasing blood pH is not a compensatory action; it is an indication of inadequate gas exchange.

The nurse is assessing a client with septic shock. What assessment data indicates a progression of shock? Select all that apply. A. BP change from 86/50 to 100/64 B. HR change from 98 to 76 C. Cool and clammy skin D. Petechiae along the gum line E. Urine output 45 ml/hr

ans: A, C, D rationale: As sepsis progresses, cardiac output is higher as are heart rate and blood pressure. The nurse would interpret the increasing blood pressure as an indication of worsening condition versus improvement. As sepsis progresses, circulation is compromised and presents as cool, clammy skin, with pallor and cyanosis. DIC can occur with sepsis progression causing petechiae and ecchymoses, occurring anywhere on the body. The decrease in heart rate is not associated with progression of shock (the heart rate, like the BP would increase). The urine output is within normal limits and would not indicate progression of shock.

A client is exhibiting signs and symptoms of early shock. Which nursing actions support the psychosocial integrity of the client? (Select all that apply.) A. Ask family members to stay with the client. B. Increase IV and oxygen rates. C. Call the health care provider. D. Remain with the client. E. Reassure the client that everything is being done for him or her.

ans: A, D, E rationale: To support the psychosocial integrity of a client in early shock, the nurse would have a familiar person nearby to comfort the client. The nurse would also remain with the client and offer genuine support to reassure the client that everything is being done for her.The health care provider would be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.

Based on the assessment data, which client will the nurse identify as having a higher risk for development of sepsis and septic shock? (Select all that apply.) A. A 40-year-old female with a history of a double lung transplant 4 years ago. B. A 41-year-old male client with a closed fracture of the femur. C. A 44-year-old female client with a history of anxiety and infertility. D. A 38-year-old male with HIV who has a low viral load. E. A 54-year-old female with breast cancer who is receiving chemotherapy. F. A 44-year-old male client who has a history of alcoholism and diabetes mellitus. G. An 86-year-old male with acute onset confusion.

ans: A, D, E, F, G. rationale: While any person can develop sepsis, there are certain conditions that predispose clients to sepsis and septic shock. The 54-year-old female is at higher risk due to cancer and chemotherapy. The 86-year-old male is higher risk due to an age above 80 years. The 44 year old has a higher risk due to alcoholism and diabetes. The 38 year old has an increased risk due to immunosuppression and HIV. The 40 year old is at higher risk due to immunosuppression and transplant status. A closed fracture does not increase risk, nor does anxiety and infertility.

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? A. Reduced urinary output and increased respiratory rate B. Low-grade fever and mild hypotension C. Low oxygen saturation rate and decreased cognition D. Localized erythema and edema

ans: B rationale: Low-grade fever and mild hypotension in a postoperative client can indicate very early sepsis. With treatment, the probability of recovery is high.Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate severe sepsis. Reduced urinary output and increased respiratory rate indicate active (not early) sepsis.

Which nurse would be assigned to care for a client who is intubated with septic shock due to a methicillin-resistant Staphylococcus aureus (MRSA) infection? A. The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago. B. The RN with 2 years of experience in intensive care unit (ICU). C. The LPN/LVN who has 20 years of experience. D. The new RN who recently finished orienting and is working independently with moderately complex clients.

ans: B rationale: The RN with 2 years ICU experience would be assigned to care for an intubated client with septic shock due to a MRSA infection. This RN with current intensive care experience who is not caring for a postoperative client is an appropriate nurse to care for this client.Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. A client who is experiencing septic shock is too complex for the new RN. Although the RN who is also caring for the post-CABG client is experienced, this assignment will put the post-CABG client at risk for MRSA infection.

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action will the nurse take first? A. Take the client's vital signs. B. Ensure that blood cultures were drawn. C. Insert an intravenous line. D. Administer the antibiotic.

ans: B rationale: The nurse's first action when planning to administer an antibiotic to a newly admitted patient in septic shock is to ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken.An intravenous line will be needed, but the nurse must ensure that blood cultures have been drawn. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 hour of shock recognition.

The nurse is teaching a client's family regarding the diagnosis of septic shock. Which teaching will the nurse include? Select all that apply. A. "The blood cultures will tell us for sure if your loved one has septic shock." B. "The client's change in behavior and lethargy may be associated with septic shock." C. "Antibiotics, as prescribed, will be started within the hour to treat the sepsis." D. "An insulin drip has been started to keep the client's glucose as low as possible." E. "Septic shock is easily treated with multiple antibiotics."

ans: B, C rationale: A recent change in behavior or altered level of consciousness are often indicators of sepsis and septic shock. Part of the sepsis bundle of care is the administration of antibiotics within one hour of recognizing sepsis. The blood cultures may or may not confirm the diagnosis of septic shock. Bacteremia may not be present. Insulin therapy is used to maintain blood glucose levels between 140 mg/dL (7.7 mmol/L) and 180 mg/dL (10 mmol/L) (Stapleton & Heyland, 2018). Keeping the blood glucose level below 110 mg/dL (6.1 mmol/L) is associated with increased mortality. Septic shock is not easily treated.

The nurse is teaching a class on the management of sepsis. What teaching will the nurse include regarding the Hour-1 sepsis management bundle? (Select all that apply.) A. Measure fibrinogen levels. B. Measure lactate levels. C. Initiate insulin therapy according to blood glucose levels. D. Administer broad spectrum antibiotics. E. Begin rapid administration of crystalloids for hypotension. F. A bundle is a group of two or more interventions that has been shown to be effective when applied in a sequence.

ans: B, D, E, F rationale: A care bundle is a group of two or more interventions that have been shown to be effective when applied in a timely sequence. The following are included in the Hour-1 Sepsis bundle:1. Measure lactate level.2. Obtain blood cultures before administering antibiotics.3. Administer broad-spectrum antibiotics.4. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mm Hg.

Which problem places a client at highest risk for sepsis? A. Client owns an iguana B. Pericarditis C. Post kidney transplant D. Pernicious anemia

ans: C rationale: A client with post kidney transplant is the highest risk for sepsis. This client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms.Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a greater risk for infection, sepsis, and death.

A postoperative client is admitted to the intensive care unit (ICU) with hypovolemic shock. Which nursing action will the nurse delegate to an experienced assistive personnel (AP)? A. Assess level of alertness. B. Obtain vital signs every 15 minutes. C. Measure hourly urine output. D. Check oxygen saturation.

ans: C rationale: The nurse delegates to an experienced ICU AP the measurement of hourly urine output for a client with hypovolemic shock. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment. The nurse will evaluate the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

Which client demonstrates the highest risk for hypovolemic shock? A. Client receiving a blood transfusion B. Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion C. Client with myocardial infarction D. Client with severe ascites

ans: D rationale: A client with severe ascites best demonstrates the problem with the highest risk for hypovolemic shock. Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion.The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle, but no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? A. Oxygen saturation remains unchanged. B. Core body temperature has increased to 99° F (37.2° C). C. The client correctly states the month and year. D. Serum lactate and serum potassium levels are declining.

ans: D rationale: Serum lactate levels and serum potassium levels both rise when shock progresses and more tissues are metabolizing under anaerobic conditions. A decline in both values indicates that the client is responding to the current interventions for hypovolemic shock. Oxygen saturation staying the same suggests that the shock is not progressing at this time but does not indicate the interventions are correcting shock. The increase in body temperature is not great enough to indicate improvement or worsening of shock. The fact that the client can correctly state the month and the year by itself does not indicate improvement because information is not provided about his or her earlier cognition or level of consciousness.

The nurse is caring for a postoperative client at risk for hypovolemic shock. Which assessment indicates an early sign of shock? A. First-degree heart block B. Blood pressure 100/48 mm Hg C. Respiratory rate 12 breaths/min D. Heart rate 120 beats/min

ans: D rationale: Tachycardia is an early symptom of shock. Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal (not hypotensive). Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal and not abnormally low. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock and are related to lack of oxygen to the heart.

When caring for a client who is obtunded and admitted with shock of unknown origin, which action will the nurse take first? A. Obtain IV access and hang prescribed fluid infusions. B. Assess level of consciousness and pupil reaction to light. C. Apply the automatic blood pressure cuff. D. Check the airway and respiratory status.

ans: D rationale: The nurse's first action when caring for an obtunded client admitted with shock is to check the client's airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority.The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

The nurse is caring for a client with hypovolemic shock that is bleeding from a traumatic injury to the upper chest wall. What is the priority nursing action? A. Insert a large bore IV catheter. B. Administer supplemental oxygen. C. Elevate the client's feet, keeping the head flat. D. Apply direct pressure to the area of overt bleeding.

ans: D rationale: The priority nursing action is to apply direct pressure to the area of overt bleeding. The nurse will first apply pressure then elevate the client's feet, administer supplemental oxygen if oxygen saturations are below 92% and insert a large bore IV catheter.

Which client has a risk for hypovolemic shock? A. A client with esophageal varices B. A client with kidney failure C. A client with arthritis taking daily acetaminophen D. A client with pain from a kidney stone

ans: A rationale: The client with esophageal varices is at risk for hypovolemic shock. Esophageal varices are caused by portal hypertension where the portal vessels are under high pressure. With this high pressure, the portal vessels are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock.As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Arthritis and daily acetaminophen use do not cause GI bleeding and hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen may predispose the client to gastrointestinal (GI) bleeding and hypovolemia. Although a kidney stone may cause hematuria, massive blood loss or hypovolemia generally does not occur.

The nurse is reviewing the laboratory profile of a client with hypovolemic shock. What lab values will the nurse anticipate? A. pH 7.51 B. PaO2 106 mmHg C. PaCO2 49 mmHg D. Lactate 0.4 mmol/L

ans: C rationale: The client with hypovolemic shock is most likely experiencing anaerobic cellular metabolism. As such, the nurse will anticipate decreased pH, decreased PaO2, increased PaCO2, and increased lactate levels.

The nurse is caring for a client in the refractory stage shock. Which intervention does the nurse consider? A. Enrollment in a cardiac transplantation program B. Admission to rehabilitation hospital for ambulatory retraining C. Collaboration with home care agency for return to home D. Discussion with family and provider regarding palliative care

ans: D rationale: When caring for a client in the refractory stage of shock, the nurse considers discussing palliative care with the family and provider. In this irreversible phase, therapy is not effective in saving the client's life, even if the cause of shock is corrected and mean arterial pressure temporarily returns to normal. A discussion on palliative care would be considered.Rehabilitation or returning home is unlikely. The client with sustained tissue hypoxia is not a candidate for organ transplantation.