Shock, Sepsis, and MODS CC Questions

A patient in heart failure is being given a first dose of lisinopril 10 mg PO. Which of the following findings would cause the nurse to question the administration of the first dose? A) Blood pressure 100/72 B) Heart rate 92 beats per minute C) Potassium 5.7 mEq/dL D) Urine output 35 mL/hr

C. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be problematic so the nurse should question the administration. The other findings are all in range for administration of the medication.

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a. Assess the blood pressure by Doppler. b. Estimate the systolic pressure as 60 mm Hg. c. Obtain an electronic blood pressure monitor. d. Record the blood pressure as "not assessable."

A Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is not appropriate without further attempts using different modalities.

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5

A Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are high and would not indicate an appropriate response to therapy.

What is the most appropriate position for a patient in pulmonary edema with a blood pressure of 194/92? A) Dorsal recumbent B) Head of the bed elevated 60 degrees C) Sitting upright with legs dependent D) Torso flat, feet elevated

C. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs dependent allows the patient to breathe more comfortably and prevents fluid from accumulating as easily in the lungs.

After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which active physician order first? a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg. b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101° F.

A Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated.

The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? a. Insertion of an 18-gauge peripheral intravenous line b. Application of cushioned heel protectors c. Implementation of fall precautions d. Implementation of universal precautions

A Given the patient's diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration. Universal precautions, fall precautions, and application of heel protectors are appropriate interventions but are not the immediate priority.

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance

A In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central line-associated bloodstream infection (CLABSI)? a. Documentation of insertion date b. Elevation of the head of the bed c. Assessment for weaning readiness d. Appropriate sedation management

A Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia.

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a. Dobutamine (Dobutrex) b. Furosemide (Lasix) c. Phenylephrine (Neo-Synephrine) d. Sodium nitroprusside (Nipride)

A Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.

The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? a. "The action of the machine will improve blood supply to the damaged heart." b. "The machine will beat for the damaged heart with every beat until it heals." c. "The machine will help cleanse the blood of impurities that might damage the heart." d. "The machine will remain in place until the patient is ready for a heart transplant."

A The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not "beat" for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system

A The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.

Two of the most common sources of infection that lead to sepsis in a patient over the age of 65 include: A) Pneumonia and urinary tract infections. B) Skin infections and diabetes. C) Surgical incisions and abdominal wounds. D) Traumatic wounds and abdominal surgeries.

A The most common source of sepsis stems from urinary tract infections and pneumonia. Among older patients, the most common source of infection is the urinary tract. The second most common source, the lungs, accounts for 35% of sepsis cases. #2 is incorrect. Skin and soft tissue account only for 7% of sepsis. Other sources only account for 8% which makes #3 and #4 incorrect.

The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

A The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical situation.

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a. Blood cultures b. Chest x-ray c. Foley insertion d. Serum electrolytes

A Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.

Which life-threatening complications would the nurse anticipate might develop in the patient who is being treated for hypovolemic shock? (Select all that apply.) A) Renal insufficiency (RI)/renal failure (RF) B) Cerebral ischemia C) Irreversible shock D) Gastric stress ulcer

A, B, C Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct responses for complications that can occur from tissue hypoxia and decreased capillary perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although physiological stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. The patient requires immediate infusion of an adequate amount of fluid.

An 82-year-old man is readmitted for heart failure (HF) 1 week after being discharged for the same diagnosis. Which of the following is likely to have contributed to his readmission? (Select all that apply.) He may: A) Be depressed. B) Not have been prescribed appropriate medications, including ACE inhibitors and beta blockers. C) Not have filled his prescribed medications. D) Not have known how or when to take his medications. E) Not have weighed himself since discharge.

A, B, C, D, E There is evidence that a significant number of older adults with HF do not receive evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE) inhibitors and beta blockers. Some studies indicate that older patients with HF have poor knowledge of appropriate diet and medication management. Pharmacy records indicate that prescriptions are not promptly refilled. Patient records indicate that daily weights are not consistently obtained. The development of HF is associated with significant cognitive impairment in the older adult and mental performance may be at least partly related to ejection fraction. Older patients with HF are more likely to be depressed and the presence of depression worsens patient outcomes.

The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output

A, C, F The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response does not assess perfusion. Respirations do not assess perfusion.

The nurse is reviewing a patient's medical history. Which of the following factors in the history are most likely to have contributed to the patient's development of heart failure? (Select all that apply.) A) Hypertension B) Diabetes mellitus C) Drinking one or two alcoholic drinks daily D) Being overweight E) Persistent atrial fibrillation

A, E. Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and drinking moderately are not known causes of heart failure. Being overweight is not a direct contributing factor, although it does increase the risk of coronary artery disease (CAD) based on the types of food that are eaten.

The nurse is caring for a patient with acute decompensated heart failure (HF) receiving BiPaP. While caring for this patient, the nurse should: A) Assess the patient for the development of gastric distention, nausea, and vomiting. B) Ensure that the mask does not fit too tightly on the patient's face to prevent skin breakdown. C) Monitor the expiratory time to be sure that it always exceeds the inspiratory time. D) Prepare for endotracheal intubation because BiPap is used primarily to buy time for intubation.

A. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also provides end-expiratory pressure, further decreasing the work of breathing. During this therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered through a tight-fitting mask. The nurse must assess the patient for complications resulting from this delivery method: TM Air leak around the mask TM Facial skin breakdown TM Gastric distention TM Vomiting and aspiration TM Claustrophobia If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be necessary to improve gas exchange in the patient with HF.

Dobutamine is often used at a moderate or high dose to improve the patients hemodynamics. The nurse knows that this medication is used because: A) It decreases systemic vascular resistance and increases perfusion to organs. B) It has no effect on systemic vascular resistance but improves oxygenation. C) It decreases the heart rate and increases oxygen delivery to the tissues. D) It increases systemic vascular resistance and improves hemodynamics.

A. Dobutamine is an inotrope that has beta-adrenergic effects. The expected outcome is to increase contractility and to vasodilate, which increases microcirculation or blood flow and organ perfusion. #2 is incorrect. Vasodilatation decreases systemic vascular resistance. #3 is incorrect. A side effect of dobutamine infusion is sinus tachycardia. #4 is incorrect. Dobutamine decreases systemic vascular resistance.

The nurse is evaluating the patient with sepsis for the development of disseminated intravascular coagulation (DIC). Which of the following is a sign that the patient may have developed this complication? A) Ecchymoses of the gums or skin B) Resistance when flushing a capped port of a central venous catheter C) A reduction in the D-dimer D) Increased fibrinogen levels

A. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. #2 is incorrect. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). #3 is incorrect because the D-dimer will be increased due to fibrinolysis. #4 is incorrect. Fibrinogen and platelets will be decreased as they are used in the clotting cascade.

Which of the following is true regarding the use of a cooling blanket to help reduce fever in a patient with sepsis? A) A cooling blanket is often considered when the patients temperature reaches 103°F. B) Shivering should be avoided because it causes a decreased metabolic rate. C) The nurse can prevent shivering by keeping the patients hands and feet on the cooling blanket. D) Sedation should be avoided during the use of the cooling blanket because it masks potential shivering.

A. Exogenous cooling is recommended when a patients temperature reaches 103°F. #2 is incorrect because shivering increases (rather than decreases) the metabolic rate. #3 is incorrect. The hands and feet should be kept off the cooling blanket (rather than on it) to prevent shivering. #4 is incorrect. The use of sedation is preferable because it decreases shivering and helps to decrease the temperature.

Which of the following is accurate about catheter-related infections? A) Statistics report that as many as one in five individuals who develop a catheter-related infection die from it. B) Nosocomial catheter-related infections prolong hospitalization by an average of 4 days. C) The increased cost of care due to the development of a bloodborne infection averages between $1,700 and $17,000. D) Central venous catheters have about the same rate of infection as peripherally inserted catheters.

A. One in five individuals who develop a catheter-related infection dies from it. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. #2 and #3 are incorrect. These infections prolong hospitalization by a mean of 7 days at a cost of $3,700 to $29,000. #4 is incorrect. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters.

Which of the following is true regarding the use of human recombinant activated protein C? A) One study showed decreased mortality of up to 13% in patients who received human recombinant activated protein C. B) The use of human recombinant activated protein C significantly improves the risk of bleeding. C) Overall mortality rates have been lower than those reported in clinical trials in those who have received human recombinant activated protein C. D) The cost of human recombinant activated protein C is too high to support its use.

A. Rivers (2001) found a decrease in mortality by 6% of those with severe sepsis, and decreased mortality of 13% in patients at risk for death. #2 is incorrect. Human recombinant activated protein C significantly increases the risk of bleeding. #3 is incorrect. Overall mortality is higher, rather than lower, in those receiving human recombinant activated protein C. #4 is incorrect. The cost of human recombinant activated protein C is not the main factor in determining its use.

The nurse is assessing the patient for septic shock. Which of the following is the best description of septic shock? A) Sepsis with hypotension that does not correct itself when a fluid challenge is administered B) Sepsis with hypotension accompanied by decreased protein C levels and coagulation abnormalities C) Sepsis with hypotension accompanied by increased creatinine and absent bowel sounds D) Sepsis with hypotension accompanied by altered mental status and lactic acidosis

A. Septic shock is defined by the presence of sepsis plus refractory hypotension. #2 is incorrect. In septic shock protein C would be elevated as a result of fibrinolysis. Both #3 and #4 describe severe sepsis with signs of organ failure but do not specifically define septic shock.

Which of the following findings would indicate that rehydration is complete and hypovolemic shock has been successfully treated in a patient? A) CVP = 7 mm Hg B) MAP = 45 mm Hg C) Urinary output of 0.1 mL/kg/hr D) Hct = 54%

A. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect. Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid-to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements.

The nurse should explain to a patient in heart failure that an aldactone antagonist works by: A) Reducing sodium and water retention. B) Filtering potassium out with the water in the renal tubules. C) Promoting the excretion of the urinary waste products urea and creatinine. D) Retaining calcium to improve the condition of blood vessels in the glomeruli.

A. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works.

A patient in heart failure is to be started on an infusion of dobutamine (Dobutrex). Which of the following is most important for the nurse to assess before starting the infusion? The patient's: A) Blood pressure. B) Level of consciousness. C) Breath sounds. D) Urine output.

A. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment of these parameters should continue throughout the infusion period.

The nurse is assessing a patient for heart failure (HF). Which early findings would reflect a decreased cardiac output and a potential for fluid overload from heart failure? A) Orthopnea, peripheral edema, crackles B) Dizziness, syncope, palpitations C) Pallor and/or cyanosis of extremities D) PAWP of 12 and CVP of 6

A. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness, syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload. These symptoms represent later symptoms of hypoxia from less blood being carried to distal organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end-organ hypoperfusion, not a fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of additional fluids must be overcome to circulate the blood.

The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.

B Assessed vital signs and hemodynamic values indicate decreased circulating volume. The patient has not responded appropriately to therapy aimed at increasing circulating volume. Additional intervention is needed because response to therapy is not appropriate, values are abnormal, and timely intervention is critical for a patient with low circulating blood volume.

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? a. Blood transfusion with packed red blood cells is required. b. Hemoglobin and hematocrit results indicate hemodilution. c. Fluid resuscitation has resulted in fluid volume overload. d. Fluid resuscitation has resulted in third spacing of fluid.

B Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins. Hemoglobin and hematocrit results indicate hemodilution. Given the clinical scenario, there is no evidence to support the need for a blood transfusion and no evidence of fluid overload. Although administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third spacing of fluid, this fact does not support the hemoglobin and hematocrit results

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

B Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.

Which evidence-based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation? A) Aseptic technique when performing oral hygiene B) Administration of an H 2 antagonist to prevent peptic ulcers C) Elevation of the head of the bed to 15 degrees to prevent aspiration D) Changing the ventilator circuit daily

B One of the evidence-based practices used to prevent ventilator-associated pneumonia includes the use of an H 2 antagonist to prevent peptic ulcers. Preventing pneumonia leads to decreased rates of sepsis. #3 and #4 are incorrect. The head of the bed should be elevated at least 30 degrees, and the ventilator circuit is changed weekly. Oral hygiene is a clean, rather than a sterile, procedure, thus #1 is incorrect.

The nurse is administering intravenous norepinephrine (Levophed) at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse? a. Blood pressure 100/60 mm Hg b. Swelling at the IV site c. Heart rate of 110 beats/min d. Central venous pressure (CVP) of 8 mm Hg

B Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine (Levophed) through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse. A blood pressure of 100/60 mm Hg, heart rate of 110 beats/min, and a CVP of 8 mm Hg are adequate and do not require immediate intervention.

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm-5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a. Furosemide (Lasix) 20 mg intravenous (IV) every 4 hours as needed for CVP > 20 mm Hg b. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain c. Dobutamine (Dobutrex) infusion at a rate of 2-20 mcg/kg/min as needed for CI < 2 L/min/m2 d. Dopamine (Intropin) infusion at a rate of 5-10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

B The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order options.

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? a. Diphenhydramine (Benadryl) 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone (Solu-Medrol) 125 mg intravenously d. Ranitidine (Zantac) 50 mg intravenously

B The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine (Benadryl) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone (Solu-Medrol), are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine (Zantac) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension

The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? a. Administer acetaminophen (Tylenol) 650-mg suppository prn every 6 hours for pain. b. Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic. c. Complete neurological assessment every 4 hours for the next 24 hours. d. Administer furosemide (Lasix) 20 mg IV every 4 hours for a CVP > 20 mm Hg.

B Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit. The nurse should question the use of the dopamine (Intropin) infusion. All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

Which of the following should the nurse identify as symptoms of hypovolemic shock? (Select all that apply.) A) A temperature of 97.6°F (36.4°C) B) A decrease in blood pressure of 20 mm Hg when the patient sits up C) Capillary refill time greater than 3 seconds D) Restlessness E) Sinus bradycardia of 55 beats per minute

B, C, D Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) a. Administer acetaminophen (Tylenol). b. Document the patient's response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the physician. f. Stop the transfusion.

B, D, E, F In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction, interventions used, and patient response to treatment are documented. Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the infusion further increases the likelihood of worsening the transfusion reaction.

Which of the following is true regarding the administration of antibiotics in a patient with sepsis? A) Antibiotics should be administered as soon as the patient has received a fluid bolus. B) Antibiotics should always be administered after blood cultures are obtained. C) If antibiotics are administered within the first 12 hours of hospital admission, mortality decreases by as much as 8%. D) Choices of specific antibiotics are often limited by the patient&#39;s liver and renal function.

B. Blood cultures must be obtained prior to the administration of antibiotics in order to isolate the infecting organism successfully. #1 is incorrect. Antibiotics should be administered as soon as possible to decrease mortality. #3 is incorrect. Mortality increases by 8% each hour that the antibiotics are delayed. #4 is incorrect because medication dosage adjustments are made to compensate for liver and kidney dysfunction rather than limiting the choices of antibiotics.

Steroids may be given by continuous infusion rather than in divided doses. What is the best rationale for this method of administration? A) Recurrent septic shock is less common when steroids are given continuously. B) Normoglycemia is maintained when steroids are given continuously. C) Vasopressor therapy can often be reduced when steroids are given continuously. D) Immunosuppression is reduced when steroids are given continuously.

B. Blood glucose levels are more stable when steroids are given continuously. #1 is incorrect. Hyperglycemia, nosocomial sepsis, and recurrent septic shock are more common when corticosteroids are given either intermittently or continuously. #3 is incorrect. Steroids are recommended when fluids and vasopressors have been necessary for resuscitation. #4 is incorrect. Immunosuppression is a side effect of corticosteroids that are given either intermittently or continuously.

Which of the following is the best description of the pathophysiology of multiple organ dysfunction syndrome (MODS) as it relates to sepsis? A) The primary cause of MODS is decreased blood pressure. B) Endothelial dysfunction is a primary cause of MODS. C) Increased microvascular bleeding causes MODS. D) Circulating pathogens cause destruction of organs, resulting in MODS.

B. Endothelial dysfunction is a primary cause of MODS. #1 is incorrect. Endothelial dysfunction occurs as a result of damage to the endothelial layers. MODS results because of a variety of factors. Vasoactive and procoagulant mediators are released. Vascular permeability and shunting occur. #3 is incorrect. Microvascular bleeding is a result, not a cause, of MODS. #4 is incorrect. Circulating pathogens does not cause destruction of organs leading to MODS.

Which of the following would the nurse not expect to find in a patient who was experiencing acute decompensated heart failure with pulmonary edema? A) Dyspnea at rest, peripheral edema B) Hypertension, bradycardia C) Increased coughing, crackles D) Decreased O2 saturation, increased PAWP

B. Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will increase when attempting to try to clear the passageways of the backed-up fluid. Due to fluid in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased pressures in the pulmonary artery.

Which of the following lab findings should cause the nurse to suspect that a patient was developing hypovolemic shock? A ) Serum sodium of 130 mEq/L (130 mmol/L) B ) Metabolic acidosis validated by arterial blood gases C ) Serum lactate of 3 mmol/L D ) SvO2 greater than 80%

B. Rationale 1: The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not reduced. Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. Rationale 3: Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Rationale 4: SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased.

Management of the patient with sepsis might include which of the following measures? A) The patient on the ventilator should have high tidal volumes to prevent adult respiratory distress syndrome (ARDS). B) The blood glucose should be less than 150 mg/dL. C) An infected wound should be stabilized and debrided after the patient has had antibiotics for 24 hours. D) CT and MRI scans should be avoided until the patient is stable.

B. The blood glucose should be maintained between 80 and 150 mg/dL. #1 is incorrect. High tidal volumes should be avoided in the presence of ARDS and do not prevent its development. #3 is incorrect. Sources of infection should be removed as soon as possible. #4 is incorrect. CT and MRI scans are often helpful in identifying causes of sepsis.

The nurse is evaluating a patient for the presence of systemic inflammatory response syndrome (SIRS). In which of the following do all measurements define SIRS? A) Temperature 36.4°C, respiratory rate 22, pulse rate 112, and PaCO 2 34 B) Temperature 38.4°C, respiratory rate 23, pulse rate 92, and PaCO 2 31 C) Temperature 37.2°C, respiratory rate 24, pulse rate 102, and PaCO 2 44 D) Temperature 38.8°C, respiratory rate 25, pulse rate 88, and PaCO 2 48

B. The definition of SIRS includes: temperature 38 degrees centigrade, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute with a PaCO 2 less than 32 torr. #1, #3 and #4 are incorrect because they are outside the parameters.

Which of the following solutions would be the most appropriate initial volume replacement for a patient with severe GI bleeding? A) 200 mL of normal saline (NS) per hour for 5 hours B) A liter of Ringer's lactate (RL) over 15 minutes C) Two liters of D5W over half an hour D) 500 mL of 0.45% normal saline (1/2 NS) over half an hour

B. The pt requires an immediate infusion of adequate fluid. 1, 3, 4 are incorrect. 1/2NS is a hypotonic solution and would not stay in the intravascular space long enough to expand circulating volume nor would it replace the lost cells need to carry oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate.

Which of the following is accurate about the sepsis management bundle? A) When all elements of the sepsis management bundle are used survival is prolonged. B) The sepsis management bundle has not received uniform support. C) The purpose of the sepsis management bundle is to improve the patients hemodynamics within 4 hours. D) The Surviving Sepsis Campaign recommends universal use of each of the elements of the sepsis management bundle to decrease mortality.

B. The sepsis management bundle has not received uniform support because the elements have not been shown to increase survival or to decrease mortality. (The seven elements of the sepsis resuscitation bundle are evidence based and were developed by the Surviving Sepsis Campaign). It is suggested that the elements of the sepsis management bundle be implemented in the first 24 hours. #1 is incorrect. Evidence has not consistently shown survival. #3 is incorrect as a result of no prior evidence for improvement in 4 hours. #4 is incorrect. The surviving sepsis campaign has recommended that each of the elements be assessed and, if appropriate that the interventions be instituted.

Which of the following findings would indicate that a patient's peripheral vascular resistance was increased? A ) Strong bounding pulse with deep red coloring B ) Pale, cool extremities with decreased pulses C ) Increased venous engorgement with strong pulses D ) Faster than normal capillary refill time

B. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance.

A patient is very short of breath. Which of the following findings should cause the nurse to be concerned that the shortness of breath might be due to heart failure? A) An echocardiogram that reflected increased right ventricular wall thickening B) A B-type natriuretic peptide (BNP) of 300 pg/mL C) A left ventricular ejection fraction (VEF) of 50% D) A serum sodium of 135

B. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with dilutional hyponatremia.

The nurse should warm intravenous fluids when a rapid infuser is being utilized in order to prevent which of the following complications? A) Hemorrhagic shock B) Hypothermia C) Sepsis D) Cardiogenic shock

B. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect. Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low cardiac output) results from poor ventricular functioning, not from the temperature of the IV fluids being administered too rapidly.

Which of the following findings would support the diagnosis of heart failure (HF)? A) CVP/RA of 8 mm Hg B) PAWP of 20 mm Hg C) Cardiac index of 3 D) Peripheral vasodilation reflected by normalizing capillary refill times

B. With HF the backup of fluid from inadequate pumping results in increased PAWP because the heart has to pump harder to push through the rising capillary pressures on the venous side from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising pressures to push through the inadequate pumping that occurs with HF from systemic venous pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is decreased with HF because the preload volume continues to rise with a less efficient pump to remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills are sluggish and delayed.

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex). The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? a. Obtain a stat serum potassium level. b. Order a stat 12-lead electrocardiogram. c. Reduce the rate of dobutamine (Dobutrex). d. Assess the patient's hourly urine output.

C Dobutamine (Dobutrex) is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states improving overall cardiac performance. The patient's cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart. There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram. Assessment of hourly urine output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario.

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102° F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids

C Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patient's heart rate.

C Given the acute nature of the patient's blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient's blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)

C Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patient's oxygen saturation is 95% on room air with an adequate respiratory rate. The application of 100% oxygen via facemask is not indicated. The patient's heart rate is adequate to support a normal blood pressure.

The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? a. Administer pain medication. b. Turn patient every 2 hours. c. Assess core body temperature. d. Apply bilateral heel protectors.

C Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body temperature is a priority. While administration of pain management, repositioning the patient every 2 hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario.

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a. Frequent turning b. Monitoring intake and output c. Enteral feedings d. Pain management

C Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa. Monitoring intake and output, frequent turning, and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission.

A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer's bolus d. Packed red blood cells

C The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.

Which of the following statements is true about serum lactate? Serum lactate is elevated in sepsis as a result of: A) Increased systemic inflammation. B) The endogenous by-products of bacterial contamination. C) Anaerobic cellular metabolism. D) Greatly accelerated coagulation.

C. Lactic acid is produced as a by-product of anaerobic cellular metabolism. #1, #2, and #4 are not related to the elevation of serum lactate in sepsis.

Which one of the following accurately describes the purpose of sedation vacation in the prevention of ventilator-associated pneumonia? A) The vacation from sedation relieves stress, which decreases the chance of infection. B) During sedation vacation the patient has a chance to take deep breaths and improve ventilation while more awake. C) The patients own tidal volume and respiratory rate can be evaluated during sedation vacation. D) New data show that sedation vacation is no longer recommended because there is concern about the safety of interrupting sedation.

C. Mechanical ventilation is discontinued sooner when close attention is given to measuring tidal volume and respiratory rate. #1 is incorrect. Sedation vacation is necessary to accurately measure tidal volume and respiratory rate, which are criteria to assess readiness to extubate. #2 and #4 are incorrect. There is concern among some nurses about the safety of interrupting sedation; therefore, most institutions have specific policies outlining for whom and when sedation interruption should be attempted. Evidence indicates that appropriate use of daily interruption of sedation to determine readiness to wean decreases patients time on a ventilator.

Which of the following hemodynamic parameters would the nurse expect to see in the patient with septic shock? A) Central venous pressure (CVP) 4 mm Hg, pulmonary artery pressure (PAP) 30/15 mm Hg, and systemic vascular resistance (SVR) 1200 dynes/sec/cm -5 B) Central venous pressure (CVP) 8 mm Hg, pulmonary artery pressure (PAP) 26/10 mm Hg, and systemic vascular resistance (SVR) 1000 dynes/sec/cm -5 C) Central venous pressure (CVP) 2 mm Hg, pulmonary artery pressure (PAP) 20/8 mm Hg, and systemic vascular resistance (SVR) 800 dynes/sec/cm -5 D) Central venous pressure (CVP) 6 mm Hg, pulmonary artery pressure (PAP) 40/20 mm Hg, and systemic vascular resistance (SVR) 700 dynes/sec/cm -5

C. Septic shock is a form of distributive shock. Central venous pressure would be low, pulmonary artery pressure would be low, and systemic vascular resistance would be low. #1, #2, and #4 are incorrect because the parameters are outside the expected for septic shock.

Which of the following is the best description of SvO 2 monitoring in septic shock? A) A SvO 2 of 65% shows that the oxygen demand of tissues is exceeding the oxygen supply. B) A SvO 2 of 95% or above shows normal oxygen supply and demand. C) A SvO 2 of 70% is adequate to deliver oxygen to body organs and tissues. D) A decrease is the SvO 2 shows that more oxygen is returning to the lungs before being metabolized.

C. The SvO 2 is a measure of systemic oxygen utilization and an indirect measure of perfusion. The normal SvO 2 is 60% to 80%. A SvO 2 of 70% is normal, indicating adequate oxygen delivery to body organs and tissues. #1 is incorrect because 65% is within the normal showing a balance. #2 is incorrect. A SvO2 of 95% is high indicating that the cardiac output is insufficient to meet the oxygen demands. #4 is incorrect. A decline is SvO2 indicates that the demand of the tissues is exceeding the oxygen delivery.

The nurse is assessing the patient for severe sepsis. Which of the following is the best description of severe sepsis? A) Decreased capillary filling and mottling B) Fever and decreased urine output C) Hypotension and lactic acidosis D) Increased glomerular filtration rate and increased D-dimer levels

C. The best description of severe sepsis is hypotension and lactic acidosis. These signs also represent altered cellular metabolism, which results in organ dysfunction. #1 and #2 are incorrect. Decreased capillary filling and mottling and fever and decreased urine output are both related to sepsis instead of severe sepsis. #4 is incorrect. In severe sepsis decreased, rather than increased, glomerular filtration rate would be expected.

The best description of the overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to: A) Increase the systolic arterial pressure. B) Provide adequate vasoconstriction. C) Increase tissue perfusion. D) Increase the metabolic rate.

C. The overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to increase tissue perfusion. Vasopressors are used if the initial fluid bolus fails to bring the mean arterial pressure over 80 mm Hg. # 1, #2 and #4 are incorrect. The goal is to maintain an adequate mean arterial pressure (increase perfusion) rather than to specifically increase systolic pressure.

The nurse knows that the use of human recombinant activated protein C is contraindicated when the patient: A) Has invasive lines in place. B) Has low platelets. C) Had a CABG 1 year ago. D) Has a history of cerebral aneurysm.

C. The use of human recombinant activated protein C is associated with a significant increase in the risk for bleeding. It is contraindicated for those who have active internal bleeding, intracranial or intraspinal lesions, and recent surgery or trauma. #1 and #2 are incorrect. Low platelets and invasive lines are not specific contraindications for the use of human recombinant activated protein C. #4 is incorrect. A history of cerebral aneurysm is not contradictory to protein C.

Which of the following findings would indicate that a patient's heart failure (HF) was worsening? A) An increase in O2 saturation to greater than 90% B) A decrease in heart rate to 66 bpm C) The onset of atrial fibrillation D) Louder S1 and S2 heart sounds

C. As HF continues to progress, less oxygenation occurs all over the body, especially the myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90% (not increase to more than 90%). Declining O2 saturation levels reflect deteriorating pulmonary status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to compensate for the decreasing O2 levels by trying to circulate what cells are present, but at the same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S1 and S2 sounds remain the same but extra sounds (S3 and S4) are noted with increased demands on the heart resulting in less synchronization.

Which of the following reasons best explains why hypotonic solutions are not used in hypovolemic shock? Hypotonic solutions: A) Move quickly into the interstitial spaces and can cause third spacing. B) Stay longer to expand the intravascular space but deplete intracellular fluid levels. C) Do not stay in the intravascular space long enough to expand the circulating blood volume. D) Need a smaller bore needle to run at a slower rate to keep the intravascular space low.

C. Not staying in the intravascular space long enough to expand the circulating blood volume is correct when describing the reason for not using hypotonic solutions to treat hypovolemic shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed. Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle does not affect the displacement or shifting of fluids.

The nurse should recognize that which of the following patients would be most likely to develop hypovolemic shock? A patient with: A ) Decreased cardiac output. B ) Severe constipation, causing watery diarrhea. C ) Ascites. D ) Syndrome of inappropriate ADH (SIADH).

C. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heart's pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema.

The nurse notes that the QRS duration of a patient with a biventricular pacemaker is widening? What does this most likely indicate? A) Battery failure B) Loss of ventricular capture C) Loss of ventricular synchronization D) Worsening of the patient's underlying cardiomyopathy

C. Widening of the QRS duration from the baseline may indicate a loss of ventricular synchronization.

During the initial stages of shock, what are the physiological effects of decreased cardiac output? a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation

D A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a. Normal body temperature b. Balanced intake and output c. Adequate pain management d. Urine output of 0.5 mL/kg/hr

D Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output

D As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In the early stages of septic shock, cardiac output is high.

The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18

D As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All other listed arterial blood gas values are within normal limits.

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures from two sites c. IV antibiotic administration d. Isotonic fluid challenge

D Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario.

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

D Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems.

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

D Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.

Which of the following is true regarding the bundle of measures used to prevent nosocomial catheter-related infections? A) Chlorhexidine is most effective when swabbed starting at the insertion site and moving outward from the site in a circular motion. B) It is recommended that transparent dressings be changed every 72 hours to prevent growth of bacteria on the skin. C) Current recommendations support changing IV tubing every 48 hours on patients at risk for catheter-related infections. D) During insertion of a central line the doctor should wear a cap and mask, sterile gloves, and a gown, and the patient should have a full body drape.

D. During insertion of a central line the doctor should wear a cap, a mask, sterile gloves, and a gown. The patient should have a full body drape. These measures prevent catheter-related sepsis. #1 is incorrect. Chlorhexidine is used in a scrubbing motion rather than in a circular motion. #2 is incorrect. An original central line dressing should be changed after 24 hours and when soiled with blood or fluid. Central line dressings may be changed every 7 days. #3 is incorrect. Current recommendations are to change IV tubing every 72 to 96 hours. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused.

In order to meet the patients nutritional needs during a critical illness with sepsis, the nurse knows that: A) TPN is the preferable means to administer nutrition to the patient with sepsis. B) Nutritional needs are usually addressed after 72 hours in order to conserve the patients energy expenditure. C) Enteral feedings are often avoided because hyperglycemia often results from feedings. D) Enteral feedings prevents translocation of bacteria from the gastrointestinal tract.

D. Enteral feedings are the preferred method of meeting the patients nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. #1 is incorrect. TPN increases the chances of hyperglycemia as well as bloodstream infections due to the high dextrose content. #2 is incorrect. Nutritional needs should be met early to promote healing, ideally before (not after) 72 hours from the time of admission. #3 is incorrect. Enteral feedings are the preferred method of meeting the patients nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract.

The goal of antibiotic therapy is to narrow the therapy to one narrow-spectrum antibiotic. What is the one rationale behind this statement? A) The use of one antibiotic ensures that the prescribed dose will result in serum concentrations that are clinically effective. B) The use of one antibiotic has been shown to cause less organ dysfunction. C) The use of one antibiotic reduces mortality in patients with sepsis. D) The use of one antibiotic limits the cost to the patient.

D. The goal is to narrow therapy once culture results identify the infecting organism. This has several benefits, including decreased cost, prevention of the development of resistance, and reduced toxicity. #1 is incorrect. Patients with sepsis have abnormal renal and hepatic function; the pharmacist should be consulted to ensure that the prescribed dose results in serum concentrations that are both clinically effective and minimally toxic (pg. 454). #2 and #3 are not factual.

After teaching a patient in heart failure about beta blocking agents, the nurse would understand that the patient required additional teaching if he said, "While taking the medication, I will: A) Weigh myself every day." B) Check my blood sugar regularly." C) Notify my health care provider if I become increasingly short of breath." D) Monitor myself daily for an increased heart rate and blood pressure."

D. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct statements that do not require additional instruction.

Which of the following statements is true about sepsis? A) Mortality rates from sepsis approached 70% worldwide in 2001. B) If managed early and aggressively, the majority of patients with sepsis may be managed outside of the ICU environment. C) The guidelines provided by the Surviving Sepsis Campaign (2004) are expected to decrease the incidence of sepsis by the year 2010. D) Sepsis rates rise sharply with age.

D. Sepsis rates rise sharply with age. #1 is incorrect. Overall mortality rates are 28% to 29% up to 38% in older individuals in the United States. #2 is incorrect because seventy percent of patients with sepsis are managed in the ICU. #3 is incorrect. Sepsis rates continue to increase due to aging of the general population, though more people are expected to survive sepsis.

When teaching a patient with heart failure about ventricular remodeling, the nurse should recognize that the patient needs additional teaching if the patient made which of the following statements? "Remodeling: A) Leads to progressive worsening of heart function." B) Can be described as an enlargement of the pumping chamber." C) Occurs with an increase in blood pressure and results in weight gain." D) Develops primarily because the heart is pumping harder."

D. This response is not true and additional teaching is needed to clarify that the contractility or elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing hypotension but by prolonged stress or injury to the myocardium such as hypertension, not hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching is required.

Which of the following findings would indicate that a patient's peripheral vascular resistance was increased? A) Strong bounding pulse with deep red coloring B) Pale, cool extremities with decreased pulses C) Increased venous engorgement with strong pulses D) Faster than normal capillary refill time

With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heart's pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema.