Shock PrepU E3
Which of the following would be a factor that may decrease myocardial contractility? a) Administration of digoxin (Lanoxin) b) Alkalosis c) Acidosis d) Sympathetic activity
Acidosis Explanation: Contractility is depressed by hypoxemia, acidosis, and certain medications, such as beta-adrenergic blocking medications. Contractility is enhanced by sympathetic neuronal activity, and certain medications, such as Lanoxin.
The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor ofthe client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record? a) Couplets b) Multifocal PVCs c) Bigeminy d) R-on-T phenomenon
Bigeminy Correct Explanation: The nurse is correct to note bigeminy on the permanent record when every other beat is a PVC. Couplets are two PVCs in a row. Multifocal PVCs originate from more than one location. R-on-T phenomenon occurs when the R wave falls on the T wave.
A 73-year-old male client is diagnosed with dilated cardiomyopathy. The nurse is aware that which of the following is the most likely cause of his condition? a) Scleroderma b) Heredity c) Chronic alcohol abuse d) Previous myocardial infarction
Chronic alcohol abuse Correct Explanation: Chronic alcohol ingestion is one of the main causes of dilated cardiomyopathy. Other causes include history of viral myocarditis, an autoimmune response, and exposure to other chemicals in addition to alcohol. Heredity is considered the main cause of hypertrophic cardiomyopathy. This a connective tissue disorder is thought to cause restrictive cardiomyopathy. Scar tissue that forms after a myocardial infarction is thought to be a cause of restrictive cardiomyopathy.
A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse a) Obtains consent by a family member for placement of a percutaneous endoscopic gastrostomy (PEG) tube b) Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) c) Begins the enteral nutritional supplement at 100 mL/hr to ensure adequate calories d) Measures the nasogastric tube from earlobe to xiphoid process and marks the tube with tape at this level
Correct response: Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) Explanation: 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.
A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is a) Packed red blood cells b) Salt-poor albumin c) Hetastarch d) Dextran
Correct response: Dextran Explanation: Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.
Which stage of shock would encompass mechanical ventilation, altered level of consciousness, and profound acidosis? a) Compensatory b) Irreversible c) Progressive d) Precompensatory
Correct response: Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.
The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage? a) Chest radiography b) Fluoroscopy c) Nuclear cardiology d) Serum blood work
Correct response: Nuclear cardiology Explanation: Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting muscle damage.
A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. a) Increasing blood pressure b) Cool, moist skin c) Increasing heart rate d) Delayed capillary refill e) Increasing urine volume
Correct response: • Cool, moist skin • Increasing blood pressure • Increasing heart rate Explanation: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.
Following a cesarean birth,what should the nurse do first: a) Obtain blood pressure and pulse. b) Observe the amount of lochia. c) Check the abdominal dressing. d) Palpate the fundus.
Correct response: • Hives, itching, and anaphylaxis may occur during an allergic reaction. • Fever, chills, headache and malaise may occur during a febrile reaction. • Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction. Explanation: An allergic reaction to transfused blood results in hives, itching, and anaphylactic reaction symptoms. If a fever develops during a transfusion (febrile reaction) the symptoms are typically headache, fever, chills and malaise. Incompatibility of blood products results in a hemolytic reaction which is characterized by facial flushing, fever, chills, headache, low back pain and shock. Dyspnea, dry cough, pulmonary edema, shortness of breath, and crackles heard in the lungs are symptoms of circulatory overload. A bacterial reaction occurs if bacteria is present in the transfusion and is characterized by symptoms such as fever, hypertension, abdominal pain and dry, flushed skin.
The nurse is assisting with a patient blood transfusion. What type of reactions may occur during this procedure? (Select all that apply.) a) Dyspnea, dry cough, and pulmonary edema may occur during a bacterial reaction. b) Fever, chills, headache and malaise may occur during a febrile reaction. c) Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction. d) Shortness of breath and auscultated crackles bilaterally in the bases may occur during a febrile reaction. e) Hives, itching, and anaphylaxis may occur during an allergic reaction. f) Fever, hypertension, abdominal pain and dry, flushed skin may occur during circulatory overload.
Correct response: • Hives, itching, and anaphylaxis may occur during an allergic reaction. • Fever, chills, headache and malaise may occur during a febrile reaction. • Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction. Explanation: An allergic reaction to transfused blood results in hives, itching, and anaphylactic reaction symptoms. If a fever develops during a transfusion (febrile reaction) the symptoms are typically headache, fever, chills and malaise. Incompatibility of blood products results in a hemolytic reaction which is characterized by facial flushing, fever, chills, headache, low back pain and shock. Dyspnea, dry cough, pulmonary edema, shortness of breath, and crackles heard in the lungs are symptoms of circulatory overload. A bacterial reaction occurs if bacteria is present in the transfusion and is characterized by symptoms such as fever, hypertension, abdominal pain and dry, flushed skin.
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) Use an intravenous controller or pump. b) Assess vital signs every hour. c) Administer through an intact peripheral line. d) Measure urine output every hour. e) Verify dosage and pump settings with another RN.
Correct response: • Use an intravenous controller or pump. • Verify dosage and pump settings with another RN. • Measure urine output every hour. Explanation: 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 should assess the client who is being admitted to the hospital with upper GI bleeding for which finding? Select all that apply. a) widening pulse pressure b) thirst c) tachycardia d) dry, flushed skin e) decreased urine output f) rapid respirations
Correct response: • decreased urine output • tachycardia • rapid respirations • thirst Explanation: The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to find are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry and flushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure.
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) instituting vital signs every 4 hours b) administering pantoprazole (Protonix) IV daily c) monitoring urine output every hour d) obtaining a urine specimen for culture e) maintaining the IV site inserted on admission
Correct response: • obtaining a urine specimen for culture • administering pantoprazole (Protonix) IV daily • monitoring urine output every hour Explanation: 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 client with acute chest pain is receiving I.V. morphine sulfate. Which is an expected effect of morphine? Select all that apply. a) prevents ventricular remodeling b) reduces myocardial oxygen consumption c) reduces blood pressure and heart rate d) reduces anxiety and fear e) promotes reduction in respiratory rate
Correct response: • reduces myocardial oxygen consumption • reduces blood pressure and heart rate • reduces anxiety and fear Explanation: Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling.
A patient who has had a recent myocardial infarction develops pericarditis and complains of level 6 (on a scale of 0-10) chest pain with deep breathing. Which of these ordered pro re nata (PRN) medications will be the most appropriate for the nurse to administer? a) Ibuprofen (Motrin) 800 mg po every 8 hours b) Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours c) Morphine sulfate 6 mg IVP every 2-4 hours d) Acetaminophen (Tylenol) 650 mg per os (po) every 4 hours
Ibuprofen (Motrin) 800 mg po every 8 hours Explanation: Pain associated with pericarditis is caused by inflammation, thus nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.
A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? a) Supine b) Modified Trendelenburg c) Trendelenburg d) Semi-Fowler's
Modified Trendelenburg Explanation: The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.
After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time? a) C-reactive protein b) Troponin I c) Myoglobin d) WBC (white blood cell) count
Myoglobin Correct Explanation: Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart damage, but troponin I levels due not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.
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) Explanation: 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.
Question: A client with a gastrointestinal bleed has vomited 600 mL of frank red blood and is now pale and diaphoretic. Vital signs are BP 88/50 mm Hg, HR 120 bpm, RR 24 breaths/min. What are the priority nursing interventions for this client? Place in order of priority. Use all options. 1 Reassess vital signs and oxygen saturation. 2Notify the physician. 3Position the client on the left side. 4Prepare the client for the operating room. 5Initiate two large-bore intravenous lines.
Position the client on the left side. Initiate two large-bore intravenous lines. Notify the physician. Reassess vital signs and oxygen saturation. Prepare the client for the operating room. Explanation: The client would immediately be placed on his/her side to avoid aspiration of bloody vomitus. Next, IVs would need to be inserted as the BP has decreased and the client is in danger of hypovolemic shock. The physician would be notified, followed by reassessment of vital signs and preparing the client for surgery.
The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include: a) Preventing fluid volume deficit. b) Decreasing myocardial contractility. c) Maintaining adequate blood pressure control. d) Minimizing dyspnea.
Preventing fluid volume deficit. Explanation: Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility.
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) Progressive b) Hypovolemic c) Compensatory d) Neurogenic
Progressive Explanation: 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.
How should vasoactive medications be administered? a) Intramuscularly (IM) b) Using a central venous line c) By rapid intravenous (IV) push d) Through a peripheral IV line
Using a central venous line Correct Explanation: Vasoactive medications should be administered through a central venous line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV push.
The nurse has received a telephone call from the emergency department indicating that a multigravid client in early labor and diagnosed with probable placenta previa will be arriving soon. What is the priority invention when the client arrives at the unit? a) internal fetal heart rate monitoring b) continuous blood pressure monitoring c) immediate cesarean birth d) whole blood replacement
continuous blood pressure monitoring Explanation: For a client diagnosed with probable placenta previa, hypovolemic shock is a complication. Continuous blood pressure monitoring with an electronic cuff is the priority assessment after the client's admission. Once the client is admitted, an ultrasound examination will be performed to determine the placement of the placenta. Whole blood replacement is not warranted at this time. However, it may be necessary if the client demonstrates signs and symptoms of hemorrhage or shock. Internal fetal heart rate monitoring is contraindicated because the monitoring device may puncture the placenta and place both the mother and fetus in jeopardy. An immediate cesarean birth is not necessary until there has been an assessment of the amount of bleeding and the location of the placenta previa.
A couple have presented to the healthcare provider for a follow up visit following the husbands myocardial infarction (MI) one week ago. The nurse knows that education on resuming intimate sexual contact should be discussed. Which of the following is correct regarding the timeline for returning to sexual intercourse? a) one month if no symptoms of chest pain b) three weeks if no symptoms of chest pain c) three months if no symptoms of chest pain d) one week if no symptoms of chest pain
three months if no symptoms of chest pain Correct Explanation: Activities of daily living, including sexual activity, should be resumed gradually, and stressors such as overexertion, alcohol consumption, and emotional upheavals should be avoided. After an uncomplicated MI, sexual activity may begin at about the third week of recovery, beginning with masturbation to partial erection in the male. Generally, this activity is gradually increased until 3 months after the MI, when sexual intercourse may be resumed. Any chest pain that occurs should be discussed with the healthcare provider prior to resuming sexual intercourse.
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) Diarrhea. d) Vomiting e) Trauma
• Burns • Dehydration Explanation: 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 client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. a) Decreases in liver enzymes b) Ecchymoses and petechiae c) Reports of chest pain d) Increased paCO² levels e) Loss in consciousness
• Ecchymoses and petechiae • Loss in consciousness • Increased paCO² levels • Reports of chest pain Correct Explanation: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activites of the liver are impaired, and liver enzymes will increase.
A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply. a) Hypotension b) Diarrhea c) Tachycardia d) A rigid, board-like abdomen e) Mild epigastric pain
• Hypotension • Tachycardia • A rigid, board-like abdomen Correct Explanation: Signs and symptoms of perforation include sudden, severe upper abdominal pain (persisting and increasing in intensity); pain, which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock. Perforation is a surgical emergency.
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) Wear clean gloves prior to accessing the line port. b) Instruct the patient to wear a face mask and gloves while the central venous line is in place. c) Always perform hand hygiene before manipulating or accessing the line ports. d) Maintain sterile technique when changing the central venous line dressing. e) Perform a 10-second "hub scrub" using chlorhexidine and friction in a twisting motion on the access hub.
• 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. Explanation: The following nursing interventions are essential to reduce the risk of infection: 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; and perform a 15- to 30-second "hub scrub" using chlorhexidine or alcohol and friction in a twisting motion on the access hub; this reduces biofilm on the hub that may contain pathogens.
Which of the following vasoactive medications may be used in the treatment of cardiogenic shock? Select all that apply. a) Norepinephrine (Levophed) b) Amrinone (Inocor) c) Phenylephrine (Neo-Synephrine) d) Milrinone (Primacor) e) Vasopressin (Pitressin)
• Norepinephrine (Levophed) • Milrinone (Primacor) • Amrinone (Inocor) Explanation: Vasoactive agents that may be used in managing cardiogenic shock include Levophed, Adrenalin, Primacor, Inocor, Pitressin, and Neo-Synephrine. Each of these medications stimulates different receptors of the sympathetic nervous system.
The nurse is planning care for a client who has experienced a myocardial infarction. Which of the following would be appropriate nursing diagnoses for the nurse to select for this client? (Select all that apply.) a) Pulmonary edema b) Fear related to change in health status c) Pain related to cardiac tissue damage d) Determine cardiac function e) Abnormal cardiac rhythm
• Pain related to cardiac tissue damage • Fear related to change in health status Correct Explanation: Fear and pain are appropriate nursing diagnoses that can be addressed by nursing care. Abnormal cardiac rhythm is an etiology. Pulmonary edema is a medical diagnosis. Determining cardiac function is the physician's domain.
A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI? Select all that apply. a) Prolonged PR-interval b) Notched T-wave c) Presence of a U-wave d) Pathologic Q-wave e) ST-segment elevation f) T-wave inversion
• T-wave inversion • ST-segment elevation • Pathologic Q-wave Explanation: T-wave inversion, ST-segment elevation, and a pathologic Q-wave are all signs of tissue hypoxia which occur during an MI. Ischemia results from inadequate blood supply to the myocardial tissue and is reflected by T-wave inversion. Injury results from prolonged ischemia and is reflected by ST-segment elevation. Q-waves may become evident when the injury progresses to infarction. A notched T-wave may indicate pericarditis in an adult client. The presence of a U-wave may or may not be apparent on a normal ECG; it represents repolarization of the Purkinje fibers. A prolonged PR-interval is associated with first-degree atrioventricular block.
A client returns to the medical-surgical floor from the postanesthesia recovery room after a colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a previous myocardial infarction. The first set of postoperative vital signs recorded are pulse rate of 110 bpm, respiration rate of 20/min, blood pressure of 130/86 mm Hg, and temperature of 98° F (36.7° C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse's response should be based on which data? Select all that apply. a) oxygen saturation b) vital sign changes c) warm, dry skin d) cyanotic mucous membrane
• cyanotic mucous membrane • vital sign changes • oxygen saturation Explanation: When assessing a postoperative client for perfusion and the manifestation of shock, nursing assessment should include an inspection for cyanotic mucous membranes; cold, moist, pale skin; and the level of oxygen saturation in relation to hemoglobin. The nurse should also compare the client's postoperative vital signs with his preoperative vital signs to determine how much physiologic stress has occurred during the intraoperative period. A client who is perfusing well would have warm, dry skin. A client well hydrated would have good skin turgor. The nurse would also assess fluid status using the intake and output record. If hemoglobin and hematocrit were available, the values would be included in the assessment.