Shock

A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action?* A. Patient heart rate is 115 bpm B. Patient experiences dyspnea and crackles in lung fields C. Patient is anxious D. Patient's urinary output is 35 mL/hr

B. Patient experiences dyspnea and crackles in lung fields

As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose __________ of their blood volume.* A. <30% B. >25% C. >15% D. >10%

C. >15%

The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient?* A. Platelets B. Albumin C. Fresh Frozen Plasma D. Packed Red Blood Cells

C. Fresh Frozen Plasma

Based on this scenario, what stage of shock is this patient most likely experiencing: A 74-year-old patient is extremely confused and does not respond to commands or stimulation. The patient respiratory rate is 28 and labored, oxygen saturation 86%, heart rate 120, blood pressure 70/40, mean arterial pressure is 50 mmHg, and temperature is 97 'F. The patient's heart rhythm is atrial fibrillation. The patient's urinary output is 5 mL/hr. The patient's labs: blood pH 7.15, serum lactate 15 mmol/L, BUN 55 mg/dL, Creatinine 6 mg/dL. In addition, the patient is now starting to have slight oozing of blood around puncture sites. A. Initial B. Proliferative C. Progressive D. Compensatory

C. Progressive

During what stage of shock is the body unable to compensate for tissue perfusion and the body's cell start to experience hypoxic injury that result in __________capillary permeability? A. Refractory, increased B. Exudative, decreased C. Compensatory, increased D. Progressive, increased

D. Progressive, increased

Which stage of shock is irreversible and unmanageable? A. Progressive B. Initial C. Exudative D. Refractory

D. Refractory

The nurse is caring for a patient newly diagnosed with sepsis. The patient has a serum lactate level of 6 mmol/L and fluid resuscitation has been initiated. Which of the following indicates that the fluid resuscitation received by the patient is adequate? A.Urine output of 0.2 mL/kg/hr B.Mean arterial pressure (MAP) of 70 mm Hg C.Central venous pressure (CVP) of 6 mm Hg D.ScvO2 of 60%

Mean arterial pressure (MAP) of 70 mm Hg

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? A."The client is in shock because the blood volume has decreased in the system." B."The client is in shock because your loved one is not responding and brain dead." C."The client is in shock because the heart is unable to circulate the body fluids." D."The client is in shock because all peripheral blood vessels have massively dilated."

"The client is in shock because the blood volume has decreased in the system."

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply. A.Neurogenic shock; diabetes B.Hypovolemic shock; blood loss C.Cardiogenic shock; myocardial infarction D.Anaphylactic shock; nuts E.Obstructive shock; kidney stone F.Septic shock; infection

-Hypovolemic shock; blood loss -Cardiogenic shock; myocardial infarction -Anaphylactic shock; nuts -Septic shock; infection

The nurse is caring for a patient with a central venous line in place for the treatment of shock. Which of the following nursing interventions are essential for the nurse to complete to reduce the risk of infection? Select all that apply. A.Always perform hand hygiene before manipulating or accessing the line ports. B.Instruct the patient to wear a face mask and gloves while the central venous line is in place. C.Perform a 10-second "hub scrub" using chlorhexidine and friction in a twisting motion on the access hub. D.Maintain sterile technique when changing the central venous line dressing. E.Wear clean gloves prior to accessing the line port.

-Maintain sterile technique when changing the central venous line dressing. -Always perform hand hygiene before manipulating or accessing the line ports. -Wear clean gloves prior to accessing the line port.

A client is unstable and receiving dopamine (Inotropin) to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all answers that apply. A.Verify dosage and pump settings with another RN. B.Administer through an intact peripheral line. C.Assess vital signs every hour. D.Use an intravenous controller or pump. E.Measure urine output every hour.

-Use an intravenous controller or pump. -Verify dosage and pump settings with another RN. -Measure urine output every hour. It is recommended to administer vasoactive drugs, such as dopamine, through a central line. The nurse assesses vital signs every 15 minutes until stable. The nurse uses an intravenous controller or pump to ensure accurate infusion and verifies the dosage and pump settings with another RN. The nurse also measures urine output every hour.

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply. A.Gait B.Vital signs C.Skin color D.Urine output E.Nutrition F.Peripheral pulses

-Vital signs -Skin color -Urine output -Peripheral pulses

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. Appropriate interventions include (Select all that apply) A.obtaining a urine specimen for culture B.instituting vital signs every 4 hours C.monitoring urine output every hour D.maintaining the IV site inserted on admission E.administering pantoprazole (Protonix) IV daily

-obtaining a urine specimen for culture -administering pantoprazole (Protonix) IV daily -monitoring urine output every hour The client is exhibiting signs of septic shock. It is important to identify the source of infection, such as obtaining a urine specimen for culture. Medication, such as pantoprazole, would be administered to prevent stress ulcers. The nurse would monitor urinary output every hour to evaluate effectiveness of therapy. IV sites would be changed and catheter tips cultured as this could be the source of infection. The client's condition warrants vital signs being assessed more frequently than every 4 hours.

A patient is admitted to the emergency department (ED) following a motorcycle accident. Upon assessment, the patient's vital signs reveal blood pressure (BP) of 80/60 mm Hg and heart rate (HR) of 145 beats per minute (bpm). The patient's skin is cool and clammy. Which of the following patient medical orders will the nurse complete first? A.100% oxygen per nonrebreather mask B.C-spine x-rays C.Type and cross match D.Two large-bore IVs and begin crystalloid fluids

100% oxygen per nonrebreather mask

The nurse is caring for a patient in cardiogenic shock. A dobutamine (Dobutrex) drip at 1 μg/kg/min is ordered for the patient. The patient weighs 90 kg. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many mL/hr? A.2.7 mL/hr B.11 mL/hr. C.5.5 mL/hr D.8.0 mL/hr

2.7 mL/hr The nurse should administer 2.7 mL/hr. 1 mcg × 90 kg × 60 minutes/2,000 (concentration)

A nurse is orienting a newly licensed nurse on the care of a patient who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates understanding?

A chest x-ray is needed to verify placement after the procedure

A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? A.Due to severe hypersensitivity reaction resulting in massive systemic vasodilation. B.A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. C.Generally caused by decreased blood volume. D.A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces.

A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.

A patient has lost 750 mL of blood volume. The MD orders Normal Saline infusion. Using the 3:1 rule, how much crystalloid solution should be prescribed by the doctor?* A. 2,250 mL of Normal Saline B. 250 mL of Normal Saline C. 375 mL of Normal Saline C. 1,225 mL of Normal Saline

A. 2,250 mL of Normal Saline

Select all the complications that can arise from the progressive stage of shock: A. Acute respiratory distress syndrome B. Extreme edema C. Elevated ammonia and lactate levels D. GI bleeding and ulcers E. Dysrhythmias F. Myocardial infraction G. Acute tubular necrosis H. Disseminated intravascular clotting

A. Acute respiratory distress syndrome B. Extreme edema C. Elevated ammonia and lactate levels D. GI bleeding and ulcers E. Dysrhythmias F. Myocardial infraction G. Acute tubular necrosis H. Disseminated intravascular clotting

You're providing an in-service to new nurse graduates on the fluid treatment for hypovolemic shock. You ask the participants to list the types of crystalloid solutions used in hypovolemic shock. Which responses are INCORRECT? Select all that apply:* A. Albumin B. Lactated Ringer's C. Normal Saline D. Hetastarch

A. Albumin D. Hetastarch

When the body is attempting to compensate for shock the adrenal cortex will release aldosterone due to the presence of angiotensin II. Select all the effects aldosterone will have on the body in attempt to increase cardiac output and maintain tissue perfusion: A. Increase blood volume B. Causes the kidneys to keep sodium and water C. Causes the kidneys to excrete sodium and water D. Cause the urine to have a low osmolality

A. Increase blood volume B. Causes the kidneys to keep sodium and water

You're providing care to a patient who has experienced a 45% loss of their fluid volume and is experiencing hypovolemic shock. The patient has hemodynamic monitoring and fluid resuscitation is being attempted. Which finding indicates the patient is still in hypovolemic shock?*A. Low central venous pressure B. High pulmonary artery wedge pressure C. Elevated mean arterial pressure D. Low systemic vascular resistance

A. Low central venous pressure

A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient?* A. Modified Trendelenburg B. Trendelenburg C. High Fowler's D. Supine

A. Modified Trendelenburg

The nurse is caring for a male patient in the early stages of sepsis. The patient is not responding well to fluid resuscitation measures and his hemodynamic status is worsening. Which of the following nursing interventions is most appropriate for the nurse to implement? A.Administer norepinephrine as prescribed. B.Begin a continuous IV infusion of insulin per protocol. C.Administer recombinant human activated protein C (rhAPC) (Xigris) as prescribed. D.Initiate enteral feedings as prescribed.

Administer norepinephrine as prescribed

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next A.Calls the Rapid Response Team B.Re-assesses the vital signs C.Contacts the admitting physician D.Administers oxygen by nasal cannula at 2 liters per minute

Administers oxygen by nasal cannula at 2 liters per minute

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? A.Anticholinergic drugs B.Adrenergic drugs C.Hormone antagonist drugs D.Antimetabolite drugs

Adrenergic drugs

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits A.Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute B.Troponin levels less than 0.35 ng/mL C.A change in apical pulse rate from 102 to 88 beats/min D.Adventitious breath sounds

Adventitious breath sounds

If a patient has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of volume loss this patient has experienced? A. 25% B. 40% C. 30% D. 10%

B. 40%

A patient has a 10% loss of their blood volume. Select all the signs and symptoms this patient may present with?* A. Cool, clammy skin B. Blood pressure within normal limits C. Anxiety D. Capillary refill less than 2 seconds E. Urinary output greater than 30 mL/hr F. Mild tachycardia

B. Blood pressure within normal limits D. Capillary refill less than 2 seconds E. Urinary output greater than 30 mL/hr

A patient is in hypovolemic shock. Select all the stages that a patient can enter when in shock: A. Proliferative B. Compensatory C. Exudative D. Initial E. Progressive F. Fibrotic G. Refractory

B. Compensatory D. Initial E. Progressive G. Refractory

During the __________ stage of shock, the signs and symptoms are very subtle. However, cells are experiencing _________ due to the lack of tissue perfusion, which causes the cells to switch from ___________ metabolism to _________ metabolism. A. Proliferative, hyperoxia, anaerobic, aerobic B. Initial, hypoxia, aerobic, anaerobic C. Compensatory, hypoxia, anaerobic, aerobic D. Fibrotic, hypoxia, aerobic, anaerobic

B. Initial, hypoxia, aerobic, anaerobic

Select all the conditions below that increases a patient's risk for absolute hypovolemic shock:* A. Burns B. Vomiting C. Long bone fracture D. Surgery E. Diarrhea F. Sepsis

B. Vomiting D. Surgery E. Diarrhea

A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to?* A. Rapidly infuse the fluids B. Warm the fluids C. Change tubing in between bags D. Keep the patient supine

B. Warm the fluids

A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following findings should the nurse expect? (Select all that apply.)

Bilateral crackles in the lungs jugular vein distension hepatomegaly

During the compensation stage of shock, what is the consequence of the release of catecholamine sin the skeletal muscles? A.Amount of air that enters the lungs decreases. B.The liver releases glycogen to provide energy. C.Blood supply to the skeletal muscles increases. D.Blood supply to the body decreases.

Blood supply to the skeletal muscles increases.

after falling from a 10ft 3meter ladder, a patient is brought to the emergency department. The patient is alert, reports back pain, and difficulty moving the lower extremities. Which additional observation is an indication the patient may be experiencing neurogenic shock? A.Cool and pale skin B.Bradycardia C.Poor skin turgor D.Increased systolic blood pressure

Bradycardia

The nurse recognizes that there are many risk factors for the development of hypovolemic shock. Which of the following are considered "internal" risk factors? Select all that apply. A.Dehydration B.Burns C.Trauma D.Diarrhea. E.Vomiting

Burns & Dehydration The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid losses) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to?* A. An increase in cardiac preload B. An increase in stroke volume C. A decrease in cardiac preload D. A decrease in cardiac contractility

C. A decrease in cardiac preload

Which statements are INCORRECT about the compensatory stage of shock. Select all that apply: A. This stage is reversible. B. During this stage blood is shunted away from the kidneys, lungs, skin, and gastrointestinal system to the brain and heart. C. During this stage blood flow to the kidneys is reduced, which causes the kidneys to activate the renin-angiotensin system, and this will lead to major vasodilation to the arterial and venous system. D. One hallmark sign of this stage is that there is an increase in capillary permeability. E. A patient is at risk for a paralytic ileus during this stage.

C. During this stage blood flow to the kidneys is reduced, which causes the kidneys to activate the renin-angiotensin system, and this will lead to major vasodilation to the arterial and venous system. D. One hallmark sign of this stage is that there is an increase in capillary permeability.

A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to? A. Collect a urine sample B. Obtain an EKG C. Establish 2 large-bore IV access sites D. Place a warming blanket on the patient

C. Establish 2 large-bore IV access sites

One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply:* A. Temperature 104.8 'F B. Heart rate 40 bpm C. Heart rate 140 bpm D. Anxiety, restlessness E. Urinary output 15 mL/hr F. Blood pressure 70/56 G. Pale, cool skin H. Weak peripheral pulses I. Blood pressure 220/106

C. Heart rate 140 bpm D. Anxiety, restlessness E. Urinary output 15 mL/hr F. Blood pressure 70/56 G. Pale, cool skin H. Weak peripheral pulses

You're caring for a patient who is experiencing shock. Which lab result below demonstrates that the patient's cells are using anaerobic metabolism? A. Ammonia 18 µ/dL B. Potassium 4.5 mEq/L C. Serum Lactate 9 mmol/L D. Bicarbonate 23 mEq/L

C. Serum Lactate 9 mmol/L

A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as A.Compensatory B.Progressive C.Circulatory D.Cardiogenic

Compensatory

A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse

Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) Pantoprazole tablets are not to be broken, crushed, or chewed. Lansoprazole is substituted for this medication. The nurse consults with the physician about substituting another proton pump inhibitor for pantoprazole. Enteral feedings are initiated at a slow rate to ensure adequate digestion. The nasogastric tube is measured from earlobe to xiphoid process and 6 inches are added to the length of the tube to be inserted. Placement of a PEG tube is not necessary at this time. The client is unstable. The tube is meant for long-term, not short-term, placement.

During what stage of shock does the body attempt to utilize the hormonal, neural, and biochemical responses of the body? A. Refractory B. Initial C. Proliferative D. Compensatory

D. Compensatory

During shock, when a patient experiences a drop in cardiac output, the body tries to compensate by stimulating the sympathetic nervous system, which causes the release of _________ and ________. This will lead to? A. acetylcholine and dopamine, vasodilation B. epinephrine and norepinephrine, vasodilation C. dopamine and epinephrine, vasoconstriction D. norepinephrine and epinephrine, vasoconstriction

D. norepinephrine and epinephrine, vasoconstriction

A patient is being treated for hemorrhagic shock secondary to multiple rib fractures and a lacerated liver. Two units of packed red blood cells have been administered. Which of these measurements is an indication the patient has received adequate volume replacement?

Decreased serum lactate

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance? A.Cover the client with a blanket. B.Shake the client to arouse. C.Place a cool compress on head. D.Elevate the legs higher than the heart.

Elevate the legs higher than the heart.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to A.Contact a spiritual advisor to provide comfort to the family. B.Inform the family that everything is being done to assist with the client's survival. C.Open up discussion among the family members about nursing home placement. D.Encourage the family to touch and talk to the client.

Encourage the family to touch and talk to the client.

The nurse is caring for a patient with a left radial arterial line, and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines?

Ensure alarm limits are turned on

A 4.5 kg infant is admitted to the pediatric intensive care unit after 3 days of watery diarrhea. The infant is diagnosed with severe dehydration. The infant's skin is mottled and turgor is poor. Capillary refill is delayed, and there is an absence of tears with crying. Which intervention should be the priority action by the healthcare provider?

Establish vascular access

TRUE or FALSE: All types of shock during the compensatory (early) stage will cause a patient to experience cold and clammy (moist or sweaty) skin. True False

False

True or False: A patient with acute pancreatitis is presenting with Turner and Cullen's Sign. This patient is at risk for absolute hypovolemic shock.* True False

False

True or False: Hypovolemic shock occurs where there is low fluid volume in the interstitial compartment.*

False

You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient? A.Hypothermia B.Bradycardia C.Coffee ground emesis D.Pain

Hypothermia

A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98.0, heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock?

Hypovolemic

The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first?

IV fluids to increase intravascular volume.

The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? A.Regulation of sodium and potassium B.Increase in arterial oxygenation C.Decreased white blood cell count D.Decreased depressive symptoms

Increase in arterial oxygenation

The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2 cm H2O, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take?

Increase the IV infusion rate

A patient who is in cardiogenic shock has a urine output of 20 mL/hr. When further assessing the patient's renal function, what additional findings are anticipated? Select all that apply.

Increased blood urea nitrogen (BUN) Decreased urine sodium

The healthcare provider is caring for a patient who has a diagnosis of cardiogenic shock secondary to left ventricular dysfunction. The goals of pharmacotherapy for this patient include which of these outcomes? Select all that apply.

Increased contractility Decreased preload

Which stage of shock would encompass mechanical ventilation, altered level of consciousness, and profound acidosis? A.Compensatory B.Irreversible C.Progressive D.Precompensatory

Irreversible

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: A.Positive increase in the fluid balance ratio B.Jugular venous distention C.Vesicular breath sounds D.Decreased pulse rate to 110 beats/minute

Jugular venous distention

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess A.Lung sounds B.Mental status C.Bowel sounds D.Skin perfusion

Lung sounds

Which of the following vasodilator medications is used in the treatment of shock? A.Dobutamine (Dobutrex) B.Nitroglycerin (Tridil) C.Dopamine (Intropin) D.Norepinephrine (Levophed)

Nitroglycerin (Tridil) Tridil is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Intropin and Dobutrex are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Levophed is a vasoconstrictor used to increase BP by vasoconstriction.

A patient is being treated in the intensive care unit for septic shock related to a gram-negative bacterial infection. Which of these are expected findings for this patient? Select all that apply.

Peripheral edema Increased WBCs with left shift

When the nurse observes that the patient's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc per hour, the nurse recognizes that the patient is demonstrating which stage of shock? A.Compensatory B.Progressive C.Irreversible D.Refractory

Progressive

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? A.Irreversible B.Progressive C.Compensatory D.Refractory

Progressive

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as A.Neurogenic B.Progressive C.Compensatory D.Hypovolemic

Progressive The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin.

You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do? A.Increases the production of antidiuretic hormone B.Increases catecholamine secretion C.Restores blood pressure D.Decreases peripheral blood flow

Restores blood pressure

A patient presents to the emergency department with and altered level of consciousness, hypotension and a weak, thready pulse. A bolus of normal saline is given but the BP remains unchanged. The patient has a bronze discoloration in the skin folds and mucous membranes, and a capillary glucose screening reveals hypoglycemia. Shock related to adrenal insufficiency is suspected. Which of these interventions should be implemented for this patient? Select all that apply.

Start an infusion of 5% percent dextrose in normal saline Administer a bolus of hydrocortisone IV Start an infusion of dopamine

An infant was delivered to a mother with a diagnosis of chorioamnionitis. The infant is lethargic, tachypneic, and has an axillary temperature of 96.8 F. The healthcare provider suspects septic shock. Which of these assessments is an indication that this infant is compensating by increasing cardiac output?

Tachycardia

When a patient is in the compensatory stage of shock, which of the following symptoms occurs? A.Urine output of 45 mL/hr B.Bradycardia C.Respiratory acidosis D.Tachycardia

Tachycardia

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? A.The client with testicular cancer who is receiving intravenous chemotherapy B.The client with pneumonia in the left lower lobe of the lung C.The client with a BMI of 25 who has lost 3 pounds as the result of vomiting D.The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs)

The client with testicular cancer who is receiving intravenous chemotherapy Risk factors for septic shock include immunosuppression, such as with the client who has testicular cancer and is receiving chemotherapy. Other risk factors include age younger than 1 year or greater than 65 years, malnourishment, chronic illness, and invasive procedures. None of the other clients meets these risk factors or has a greater risk for invasive procedures than the client with testicular cancer.

A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120 beats/minute, blood pressure 80/55 mmHg, urine output 20 mL/hr. After administering an IV fluid bolus, which of these signs if noted by the healthcare provider is the best indication of improved perfusion? A.Right atrial pressure increases B.Systolic blood pressure increases to 85 mmHg C.Urine output increases to 30 mL/hour D.Heart rate drops to 100 beats/minute

Urine output increases to 30 mL/hour

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?

administer furosemide 40mg IV

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

c.Increase the rate for the sodium nitroprusside infusion.

A client presents to the ED in shock. During what phase of shock does the nurse know that metabolic acidosis is going to most likely occur? A.early B.compensation C.decompensation D.irreversible

decompensation The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.

A child is brought to the emergency room by his mother who reports the child was stung by a bee while playing in the back yard. The child has an itchy rash on the face, neck, and chest. Breathing is labored with audible wheezing. Which of these medications should the healthcare provider administer first?

epinephrine

When performing an initial pulmonary artery occlusion pressure (PAOP), what is the best nursing action?

inflate the balloon with air, recording the volume necessary to obtain a reading.

A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg, drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock?

obstructive

Vasoactive drugs, which cause the arteries and veins to dilate thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as A.furosemide (Lasix). B.dopamine (Intropin). C.norepinephrine (Levophed). D.sodium nitroprusside (Nipride).

sodium nitroprusside (Nipride). Sodium nitroprusside is used in the treatment of cardiogenic shock. Norepinephrine (Levophed) is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine (Intropin) tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide (Lasix) is a loop diuretic that reduces intravascular fluid volume.

What is the best position for the nurse to place the patient in to obtain a central venous pressure measurement?

supine, either flat or with the head of bed no more than 60 degrees