Shock & Burns
Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.
ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful.
When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? a. BP 92/56 mm Hg b. Skin cool and clammy c. Apical pulse 118 beats/min d. Arterial oxygen saturation 91%
ANS: B Since patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing.
A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate a. infusion of 5% human albumin. b. administration of furosemide (Lasix) IV. c. titration of an epinephrine (Adrenalin) drip. d. administration of hydrocortisone (SoluCortef).
ANS: B The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. Normal saline infusion would increase the PAWP further. Hydrocortisone might be used for septic or anaphylactic shock.
When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective? a. No heart murmur is audible. b. Skin is warm, pink, and dry. c. Troponin level is decreased. d. Blood pressure is 90/40 mm Hg.
ANS: B Warm, pink, and dry skin indicates that perfusion to tissues is improved.
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2° F (38.4° C)
ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.
Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation
ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment.
The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions? (select all that apply) a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Infuse vasopressin (Pitressin) 0.01 units/min. d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.
ANS: E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.
A patient is receiving fluid boluses to treat hypovolemic shock. For which of the following assessment findings should the nurse stop the fluid boluses and notify the physician? A. Tachycardia and hypotension. B. Crackles throughout the lung fields. C. Peripheral cyanosis. D. Increased oxygen saturation percentages.
B. Crackles throughout the lung fields.
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: 98.0F (36.3C), heart rate: 130beats/minute, respiration rate: 34breaths/minute, blood pressure: 50/40mmHg. The healthcare provider suspects which type of shock? A. Cardiogenic B. Hypovolemic C. Neurogenic D. Distributive
B. Hypovolemic
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? A. Diphenhydramine B. Albuterol C. Epinephrine D. Dopamine
C. Epinephrine
A 4.5kg 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? A. Calculate the mean arterial pressure B. Draw blood for a complete blood count C. Establish vascular access D. Take a complete set of vital signs
C. Establish vascular access
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? A. Antibiotics to treat the underlying infection. B. Corticosteroids to reduce inflammation. C. IV fluids to increase intravascular volume. D. Vasopressors to increase blood pressure
C. IV fluids to increase intravascular volume.
The nurse would expect to find which of the following symptoms in a patient with end-organ hypoperfusion heart failure? A. Increased blood pressure (BP) and decreased heart rate (HR). B. Increased exercise tolerance. C. Palpitations and prolonged capillary refill times. D. Paroxysmal noctural dyspnea (PND).
C. Palpitations and prolonged capillary refill times.
A patient has jugular venous distention, an enlarged liver and ascites. Which of the following objective findings would the nurse also expect to find? A. PAWP 12 mmHg. B. PA pressure 25/12. C. RA pressure 18. D. Weight gain of 2 pounds in the past month.
C. RA pressure 18.
A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120 beats/minute, blood pressure 80/55mmHg, and urine output 20mL/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 85mmHg C. Urine output increases to 30mL/hour D. Heart rate drops to 100beats/minute
C. Urine output increases to 30mL/hour
After falling from a 10 foot (3 meter) 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. Increased systolic blood pressure C. Poor skin turgor D. Bradycardia
D. Bradycardia
When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize? A. Intensity of peripheral pulses and body temperature. B. Peripheral pulses and heart rate (HR). C. Metabolic alkalosis and oxygen saturation. D. Cardiac output (CO) and blood pressure (BP).
D. Cardiac output (CO) and blood pressure (BP).
The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2cm H2O, blood pressure is 90/50mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? A. Slow the IV infusion rate B. Administer dopamine C. No interventions are needed at this time D. Increase the IV infusion rate
D. Increase the IV infusion rate
Which of the following symptoms is much more likely to be present in the older patient with heart failure than a younger individual? A. Crackles in dependant lobes. B. Decreased urine output. C. Peripheral edema. D. Significant cognitive impairment.
D. Significant cognitive impairment.
An emergency department nurse is performing an assessment on a client who has sustained circumferential burns on both legs. Which assessment would be the priority in caring for this client? a) assessing peripheral pulses b) assessing neurological status c) assessing urine output d) assessing blood pressure
a) assessing peripheral pulses
A nurse has developed a nursing care plan for a client following a burn injury includes a nursing diagnosis of Deficient Fluid Volume. Which nursing intervention is appropriate to include in the plan of care? a) obtain and record weight every other day b) monitor intake and output every shift c) monitor mental status every hour d) monitor vital signs every 4 hours
c) monitor mental status every hour
A patient who has sustained multiple trauma has arrived to the emergency department. Place the assessments in order of priority. A. Airway patency B. Respiratory rate and breath sounds C. Presence of external bleeding D. Level of consciousness
A. Airway patency B. Respiratory rate and breath sounds C. Presence of external bleeding D. Level of consciousness
Which type of fluid is most appropriate for volume replacement for a patient with non-hemorrhagic hypovolemic shock? A. Lactated Ringers (LR) B. 10% Dextrose in Water (D 10 W) C. One-half Normal Saline (1/2% NS) D. Packed Red Blood Cells (PRBC)
A. Lactated Ringers (LR)
When delivering care to a patient with acute decompensated heart failure with pulmonary edema, the nurse should expect to provide which of the following collaborative interventions? (Select all that apply) A. Titrate the FiO2 to maintain oxygen saturation levels above 92%. B. Use a 100% non-rebreather mask to minimize or avoid hypercarbia if necessary. C. Reduce the workload of breathing (WOB) by sitting the patient upright. D. Maintain the heart rate above 100 to increase the circulation of oxygen. E. Increase the PAWP to at least 22 to maximize the stroke volume (SV).
A. Titrate the FiO2 to maintain oxygen saturation levels above 92%. B. Use a 100% non-rebreather mask to minimize or avoid hypercarbia if necessary. C. Reduce the workload of breathing (WOB) by sitting the patient upright.
A patient with heart failure says he doesn't think he should take his Beta-blocking agent anymore since it makes his heart beat less forcefully. How might the nurse explain the development of heart failure so that the patient could understand the necessity of this medication? In heart failure A. Your blood vessels are very constricted and your heart beats too quickly, a beta blocker can help to fix these things. B. The part of your nervous system that lets your heart slow down is not working, a beta blocker can help. C. The walls of your heart have gotten too thin and a beta blocker will help them to regrow. D. Your heart rate is too slow and a beta blocker will help to regulate it.
A. Your blood vessels are very constricted and your heart beats too quickly, a beta blocker can help to fix these things.
A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Infuse drotrecogin-(Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.
ANS: A Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy.
The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? a. The patient's IV infusion site is cool and pale. b. The patient has warm, dry skin on the extremities. c. The patient has an apical pulse rate of 58 beats/min. d. The patient's urine output has been 28 mL over the last hour.
ANS: A The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line.
Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient has crackles throughout both lung fields. d. The patient's extremities are cool and pulses are weak.
ANS: A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patient's diagnosis of cardiogenic shock.
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. attach a cardiac monitor. c. obtain the blood pressure. d. check the level of consciousness.
ANS: A The initial actions of the nurse are focused on the ABCs—airway, breathing, circulation—and administration of oxygen should be done first.
A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg. d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.
A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c. Administer hydrocortisone (SoluCortef) 100 mg IV. d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.
ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.
Which of the following assessment findings is an early indication of hypovolemic shock? A. Diminished bowel sounds B. Increased urinary output C. Tachycardia D. Hypertension
C. Tachycardia
A patient who is in cardiogenic shock has a urine output of 20mL/hr. When further assessing the patient's renal function, what additional findings are anticipated? Select all that apply. A. Decreased urine specific gravity B. Increased blood urea nitrogen (BUN) C. Decreased urine sodium. D. Decreased serum creatinine
B. Increased blood urea nitrogen (BUN) C. Decreased urine sodium.
A patient in heart failure is started on beta blocker therapy with carvedilol (Coreg). During the first few hours after initiation of therapy, it is most important for the nurse to monitor the patient's A. blood pressure and pulse. B. ejection fraction. C. respiratory rate and breath sounds. D. weight.
A. blood pressure and pulse.
A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. d. Administer large volumes of lactated Ringer's solution. e. Administer high-flow oxygen (100%) by non-rebreather mask.
ANS: A, B, C, E All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.
The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. 500 mL of 5% albumin. b. lactated Ringer's solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.
ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline.
When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Decreasing the room temperature to 68° F for a patient with neurogenic shock d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
ANS: C Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia.
To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse make? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Monitor stools for occult blood. d. Check for abdominal distention.
ANS: C Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the omeprazole administration.
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Avoid elevating head of bed. b. Check temperature every 2 hours. c. Monitor breath sounds frequently. d. Assess skin for flushing and itching.
ANS: C Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea.
After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
ANS: C When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR.
A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion. b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion. d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.
ANS: D Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR.
During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation
ANS: D The changes in mental status are indicative that the patient is in the progressive stage of shock
A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first? a. Place the patient on continuous cardiac monitor. b. Draw blood to type and crossmatch for transfusions. c. Insert two 14-gauge IV catheters in antecubital space. d. Administer oxygen at 100% per non-rebreather mask
ANS: D The first priority in the initial management of shock is maintenance of the airway and ventilation.
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? A. Oxygen saturation 90% B. Increased serum creatinine C. Decreased right atrial pressure D. Decreased serum lactate
D. Decreased serum lactate
An infant was delivered to a mother with a diagnosis of chorioamnionitis. The infant is lethargic, tachypneic, and has an axillary temperature of 96.8F (36.0C). The healthcare provider suspects septic shock. Which of these assessments is an indication that this infant is compensating by increasing cardiac output? A. Active precordium B. Warm, flushed skin C. Bounding pulses D. Tachycardia
D. Tachycardia
A nurse is preparing to administer 3mg of morphine IV to a patient in acute decompensated heart failure. Which of the following is a desired effect of the morphine? A. a decrease in level of consciousness. B. an increase in blood pressure to 140/76. C. a reduction in the respiratory rate to 8 breaths per minute. D. an increase in the oxygen saturation.
D. an increase in the oxygen saturation.
A nurse is developing a care plan for a client with a circumferential burn injury of the extremity. The nursing diagnosis states Ineffective Tissue Perfusion. Which nursing intervention would the nurse include in the plan of care for the client? a) monitor peripheral pulses every hour b) keep the extremities in a dependent position c) document any changes that occur in the pulse d) place pressure dressings and wraps around the burn sites
a) monitor peripheral pulses every hour
An industrial nurse is providing instructions to a group of employees regarding care to a victim in the event of a chemical burn injury. The nurse instructs the employees that the immediate action would be to: a) leave all clothing in place until the client is brought to the emergency department b) remove all clothing, including gloves and shoes c) lavage the skin with water, and avoid brushing powdered chemicals off the clothing to prevent further spread of injury d) determine the antidote for the chemical and place the antidote on the burn site
b) remove all clothing, including gloves and shoes
An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. On assessment of the client, which finding would indicate that the client also sustained a respiratory injury as a result of the burn? a) clear breath sounds b) use of accessory muscles for breathing c) fear and anxiety d) complaints of pain
b) use of accessory muscles for breathing
A nurse has developed a nursing diagnosis of Ineffective Airway Clearance for a client who sustained an inhalation burn injury. Which nursing intervention would the nurse include in the plan of care for the client? a) monitor oxygen saturation levels every shift b) encourage coughing and deep breathing every 4 hours c) elevate the head of the bed continually d) assess respiratory rate and breath sounds every 2 hours
c) elevate the head of the bed continually
