143 Module 1: Shock (PRACTICE QUESTIONS)

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) A. Urinary output B. Visual acuity C. Vital signs D. Ability to perform range of motion exercises E. Mental status

A, C, E. Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. The patient receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema.

A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply. A. dobutamine B. nitroglycerin C. nitroprusside D. epinephrine E. dopamine

A, D, E. Dobutamine (Dobutrex), dopamine (Intropin), and epinephrine (Adrenalin) are inotropic agents used to improve client's contractility. Nitroprusside (Nipride) and nitroglycerin (Tridil) are vasodilators used to reduce preload and afterload, reducing oxygen demand in the heart.

Which colloid is expensive but rapidly expands plasma volume? A. Albumin B. Dextran C. Hypertonic saline D. Lactated Ringer solution

A. Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next? A. ondansetron B. magnesium hydroxide C. meperidine D. loperamide

A. An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: A. Blood pressure. B. Breath sounds. C. Heart rate. D. Renal output.

A. By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: A. A myocardial infarction. B. Valvular damage. C. Arrhythmias. D. Cardiomyopathies.

A. Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? A. 70% B. 40% C. 60% D. 50%

A. Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? A. Septic B. Neurogenic C. Cardiogenic D. Anaphylactic

A. In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardia, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.

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

A. The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

The nurse is caring for a client who develops hypotension, declining mental status, and severely decreased urinary output. Which intravenous fluid will the nurse expect to be prescribed for this client? A. Lactated Ringer's solution B. 0.9% normal saline C. Dextrose 5% and 0.9% normal saline D. 3% sodium chloride

A. The nurse is caring for a client who develops hypotension, declining mental status, and severely decreased urinary output. Which intravenous fluid will the nurse expect to be prescribed for this client?

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

A. The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? A. Circulatory (distributive) B. Obstructive C. Carcinogenic D. Hypovolemic

A. Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.

A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. A. Blood urea nitrogen (BUN) level B. Urine specific gravity C. Alkaline phosphatase level D. Creatinine level E. Serum albumin level

ANS: A, B, D. Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acid-base imbalances, and a loss of the renal-hormonal regulation of BP. Urine specific gravity is also affected. Alkaline phosphatase and albumin levels are related to hepatic function.

The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. A. Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines B. Hypotension that responds to bolus fluid resuscitation C. Exaggerated response to vasoactive medications D. Serum lactate greater than 4 mmol/L E. Mean arterial pressure (MAP) of less than 65 mm Hg

ANS: A, D, E. Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or MAP <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines, or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted.

A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply. A. Anaphylactic B. Hypovolemic C. Cardiogenic D. Septic E. Neurogenic

ANS: A, D, E. The varied mechanisms leading to the initial vasodilation in distributive shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of distributive shock.

A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care? A. Communicate clearly and frequently with the client's family. B. Taper down interventions slowly when the prognosis worsens. C. Transfer the client to a subacute unit when recovery appears unlikely. D. Ask the client's family how they would prefer treatment to proceed.

ANS: A. As it becomes obvious that the client is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided throughout the client's care for the family to see, touch, and talk to the client. However, the onus should not be placed on the family to guide care. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The client would not be transferred to a subacute unit.

The nurse in the emergency department is caring for a client recently admitted with a likely myocardial infarction (MI). The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at an increased risk for MI due to which factor? A. Arrhythmias B. Elevated B-natriuretic peptide (BNP) C. Use of thrombolytics D. Dehydration

ANS: A. Cardiogenic shock occurs when the heart's ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. An elevated BNP is noted after an MI has occurred and does not increase risk. Use of thrombolytics decreases risk of developing blood clots. Dehydration does not lead to MI.

The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer? A. Lactated Ringer B. Albumin C. Dextran D. 3% NaCl

ANS: A. Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. The 3% NaCl is a hypertonic solution and is not isotonic.

The nurse is caring for a client in intensive care unit whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. Which assessments and interventions should the nurse prioritize? A. Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration B. Reviewing medications, performing a focused cardiovascular assessment, and providing client education C. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema D. Routine monitoring of vital signs, monitoring the peripheral intravenous site, and providing early discharge instructions

ANS: A. Dopamine is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. When vasoactive medications are given, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated), not routinely. Vasoactive medications should be given through a central, not peripheral, venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. High doses can cause vasoconstriction, which increases afterload and thus increases cardiac workload. Because this effect is undesirable in clients with cardiogenic shock, dopamine doses must be carefully titrated. Reviewing medications and laboratory findings, monitoring urine output, assessing for peripheral edema, performing a focused cardiovascular assessment, and providing client education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs.

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? A. Fluid volume circulating in the blood vessels decreases. B. There is an uncontrolled increase in cardiac output. C. Blood pressure regulation becomes irregular. D. The client experiences tachycardia and a bounding pulse.

ANS: A. Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.

The nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion? A. The client is in the compensatory stage of shock. B. The client is in the progressive stage of shock. C. The client will stabilize and be released by tomorrow. D. The client is in the irreversible stage of shock.

ANS: A. In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Clients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the client's chance of survival is low and he will certainly not be released within 24 hours. If the client were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.

A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client's plan of care while the client is ventilated? A. Performing frequent oral care B. Maintaining the client in a supine position C. Suctioning the client every 15 minutes unless contraindicated D. Administering prophylactic antibiotics, as prescribed

ANS: A. Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.

The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor? A. Hypothermia B. Bradycardia C. Coffee ground emesis D. Pain

ANS: A. Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the client for cardiovascular overload and pulmonary edema when large volumes of IV solution are given. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock.

The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way? A. Through a central venous line B. By a gravity infusion IV set C. By IV push for rapid onset of action D. Mixed with parenteral feedings to balance osmosis

ANS: A. Whenever possible, vasoactive medications should be given through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition.

A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply. A. Hypovolemia B. Difficulty breathing C. Cardiovascular overload D. Pulmonary edema E. Hypoglycemia

ANS: B, C, D. Fluid replacement complications can occur, often when large volumes are given rapidly. Therefore, the nurse monitors the client closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement.

A triage nurse in the emergency department (ED) is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while they were waiting for the child's parent to get off work. Rapid onset of which condition would lead the nurse to suspect that the child is experiencing anaphylactic shock? A. Acute hypertension B. Respiratory distress C. Neurologic compensation D. Cardiac arrest

ANS: B. Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur later if prompt treatment is not provided.

An 11-year-old client has been brought to the emergency department by their parent, who reports that the client may be having a really bad allergic reaction to peanuts after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. Which interventions should the nurse prioritize? A. Establishing central venous access and beginning fluid resuscitation B. Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR) C. Establishing peripheral intravenous (IV) access and administering IV epinephrine D. Performing a comprehensive assessment and initiating rapid fluid replacement

ANS: B. If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. A patent airway is also an immediate priority. Epinephrine is not withheld pending IV access, and fluid resuscitation is not a priority.

A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock

ANS: B. Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention? A. Reviewing the cause of shock and prioritizing the client's psychosocial needs B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C. Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive D. Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock

ANS: B. Nursing care of clients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of clients in shock; thus, suspecting that a client may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.

The nurse in the intensive care unit is caring for a 47-year-old, obese client who is in shock following a motor vehicle accident. What would be the main challenge in meeting this client's elevated energy requirements during prolonged rehabilitation? A. Loss of adipose tissue B. Loss of skeletal muscle C. Inability to convert adipose tissue to energy D. Inability to maintain normal body mass

ANS: B. Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the client has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the client's recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, and the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this client.

A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem? A. Blood is shunted from vital organs to peripheral areas of the body. B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C. Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.

ANS: B. Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells do not have an adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.

An adult client has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this client. What aspect of this care should be prioritized by the home health nurse? A. Providing supervision to home health aides in providing necessary client care B. Assisting the client and family to identify and mobilize community resources C. Providing ongoing medical care during the family's rehabilitation phase D. Reinforcing the importance of continuous assessment with the family

ANS: B. The home care nurse reinforces the importance of continuing medical care and helps the client and family identify and mobilize community resources. The home health nurse is part of a team that provides client care in the home. The nurse does not directly supervise home health aides. The nurse provides nursing care to both the client and family, not just the family. The nurse performs continuous and ongoing assessment of the client; he or she does not just reinforce the importance of that assessment.

A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? A. The drug should be discontinued immediately after blood pressure increases. B. The drug dose should be tapered down once vital signs improve. C. The client should have arterial blood gases drawn every 10 minutes during treatment. D. The infusion rate should be titrated according the client's subjective sensation of adequate perfusion.

ANS: B. When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but draws every 10 minutes are not the norm.

The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock? A. Elevated systolic blood pressure B. Elevated mean arterial pressure (MAP) C. Shallow, rapid respirations D. Bradycardia

ANS: C. A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.

The ICU nurse is caring for a client in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the client? A. Anaphylaxis B. Decreased oxygen consumption C. Abdominal compartment syndrome D. Decreased serum osmolality

ANS: C. Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are given. The scenario does not describe an antigen- antibody reaction of any type. Decreased oxygen consumption by the body is not a concern in hypovolemic shock. With a decrease in fluids in the intravascular space, increased serum osmolality would occur.

The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock? A. Increased hunger B. Decreased thirst C. Decreased urinary output D. Increased capillary perfusion

ANS: C. During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further retain water in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary perfusion decreases as the body shunts blood away from the periphery and to the vital organs.

The ICU nurse is caring for a client in neurogenic shock following an overdose of anti anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock? A. Hypertension B. Cool, moist skin C. Bradycardia D. Signs of sympathetic stimulation

ANS: C. In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs? A. The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate B. The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements D. The increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea

ANS: C. Nutritional support is an important aspect of care for clients in shock. Clients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.

A critical care nurse is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock? A. Aggressive hypoglycemic control B. Administration of hypertonic IV fluids C. Early provision of nutritional support D. Aggressive antibiotic therapy

ANS: C. Nutritional support is necessary for all clients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many clients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in clients with septic shock.

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention? A. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months C. Promoting communication with the client and family along with addressing end-of-life issues D. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

ANS: C. Promoting communication with the client and family is a critical role of the nurse with a client in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the client's wishes. Many cases of MODS result in death, and the life expectancy of clients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the client.

The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state? A. Third spacing of fluid B. Dysrhythmias C. Tachycardia D. Gastric hypermotility

ANS: C. Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms.

16. The nurse in a rural nursing facility will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after giving birth at home. Which principle should guide the nurse's administration of intravenous fluid? A. 5% albumin is preferred because it is inexpensive and is always readily available. B. Dextran should be given because it increases intravascular volume and counteracts coagulopathy. C. Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency. D. Lactated Ringer solution is ideal because it increases volume, buffers acidosis, and is the best choice for clients with liver failure.

ANS: C. The best fluid to treat shock remains controversial. In emergencies, the best fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids can be administered to restore intravascular volume. There is no consensus regarding whether crystalloids or colloids, such as dextran and albumin, should be used; however, with crystalloids, more fluid is necessary to restore intravascular volume. Albumin is very expensive and is a blood product so it is not always readily available for use. Dextran does increase intravascular volume, but it increases the risk for coagulopathy. Lactated Ringer is a good solution choice because it increases volume and buffers acidosis, but it should not be used in clients with liver failure because the liver is unable to convert lactate to bicarbonate. This client does not have liver disease.

The intensive care unit nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring? A. Urinary output increases B. Skin becomes warm and dry C. Adventitious lung sounds occur in the upper airway D. Heart and respiratory rates are elevated

ANS: D. As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the client begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., acute kidney injury, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.

An immunocompromised 65-year-old client has developed a urinary tract infection, and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. Which action should the nurse perform to reduce the client's risk of septic shock? A. Apply an antibiotic ointment to the client's mucous membranes, as prescribed. B. Perform passive range-of-motion exercises unless contraindicated. C. Initiate total parenteral nutrition (TPN). D. Remove invasive devices as soon as they are no longer needed.

ANS: D. Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.

The nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client? A. It promotes coping and slows catecholamine release. B. It stimulates the client so he or she is more alert. C. It decreases gastric secretions. D. It dilates the blood vessels.

ANS: D. For clients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the client's anxiety. Morphine would not be prescribed to promote coping or to stimulate the client. The rationale behind using morphine would not be to decrease gastric secretions.

The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A. Increased urine output B. Decreased heart rate C. Hyperactive bowel sounds D. Cool, clammy skin

ANS: D. In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? A. It slows the proliferation of bacteria and viruses during shock. B. It decreases the energy expended through the functioning of the GI system. C. It assists in expanding the intravascular volume of the body. D. It promotes GI function through direct exposure to nutrients.

ANS: D. Parenteral or enteral nutritional support should be initiated as soon as possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feeding. Enteral feeding does not decrease the proliferation of microorganisms or the amount of energy expended through the functioning of the GI system and it does not assist in expanding the intravascular volume of the body.

The intensive care unit nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of: A. increased stroke volume. B. increased cardiac output. C. decreased heart rate. D. decreased venous return.

ANS: D. Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.

When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal? A. Provide a detailed diagnosis and plan of care in order to promote the client's and families coping. B. Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C. Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature. D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

ANS: D. Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the client with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the health care provider updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the client the best chance for survival. Monitoring for significant changes is critical, and evaluating client outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.

The intensive care unit nurse is caring for an acutely ill client with signs of multiple organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing MODS due to all of the following EXCEPT: A. Malnutrition B. Advanced age C. Multiple comorbidities D. Progressive dyspnea

ANS: D. The client with advanced age is at risk for developing MODS due to the lack of physiological reserve. The client with malnutrition metabolic compromise and the client with multiple comorbidities is at risk for developing MODS due to decreased organ function. Progressive dyspnea is the first sign of MODS.

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? A. Absence of infarcts or emboli B. Reduced stroke volume and cardiac output C. Absence of pulmonary and peripheral edema D. Maintenance of adequate mean arterial pressure

ANS: D. Vasoactive medications can be given in all forms of shock to improve the client's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.

A patient being treated for a severe infection has a temperature of 35.8°C. Which additional finding would indicate to the nurse that initiation of treatment for sepsis is likely? 1. A shift to the left on the white blood cell differential 2. Heart rate 88 3. Respiratory rate 10 4. Acute alteration in mental status

Answer: 1 Explanation: 1. Greater than 10% bands on the white blood cell differential, or a shift to the left, along with this temperature would indicate sepsis has developed. 2. Heart rate over 90, along with this temperature, indicates sepsis is present. 3. Respiratory rate greater than 20, along with this temperature, indicate sepsis is present. 4. Acute alteration in mental status is related to development of severe sepsis.

A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patient's mental status? 1. Temporarily discontinue the drip and assess mental status within a few minutes. 2. Temporarily discontinue the drug and plan to assess mental status in an hour. 3. Use train of four testing while the medication is still infusing. 4. This assessment will have to wait until the sedating drug is no longer needed.

Answer: 1 Explanation: 1. Propofol has a very short half-life, so assessment of mental status can occur within a few minutes of the drug's discontinuation. 2. Benzodiazepines used for sedation require discontinuation of the drug for a longer time in order for mental status assessment to be valid. 3. Train of four testing is used when the patient is receiving neuromuscular blocking agents. 4. Mental status should be assessed frequently and cannot be safely deferred until sedation is no longer needed.

A patient who underwent transurethral resection of the prostate 5 days ago comes to the emergency department with the report of feeling worse than before the surgery. After assessing the patient and obtaining laboratory results, the nurse notes a temperature of 96.6°F, a respiratory rate of 26, and a white blood cell (WBC) count of 3000 mm3. The nurse anticipates additional treatment for which disorder? 1. Systemic inflammatory response syndrome 2. Homeostasis 3. Localized inflammation 4. Multiple organ dysfunction syndrome

Answer: 1 Explanation: 1. Systemic inflammatory response syndrome is correct because the clinical manifestations include a respiratory rate of greater than 20 breaths per minute and a white blood cell count below 4000/mm3. These findings meet the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria of sepsis. 2. Homeostasis is incorrect because the clinical manifestations are not compatible with the state of equilibrium found in homeostasis. 3. Localized inflammation may exist and contribute to the patient's condition, but is not the specific problem of concern. 4. There is no indication of the failure of organ systems.

Which finding would cause the nurse to be concerned that a patient who sustained chest trauma is experiencing cardiac tamponade? 1. Distant heart sounds 2. Decrease of right arterial pressure 3. Sudden development of hypertension 4. Development of an S3 heart sound

Answer: 1 Explanation: 1. The presence of blood in the pericardial space makes the heart tones sound muffled or distant. 2. Right arterial pressure increases with cardiac tamponade. 3. Hypotension is associated with cardiac tamponade due to the heart's inability to fill. 4. S3 heart sounds are not associated with cardiac tamponade.

A patient was admitted to the emergency department for treatment of severe infection. Which objective parameters would increase the nurse's concern that shock is developing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Serum lactate level is 5.4 mmol/L. 2. Base deficit is −9 mmol/L. 3. SvO2 is 68%. 4. pHi is 6.9. 5. Arterial pH is 7.38.

Answer: 1, 2, 4 Explanation: 1. Lactate is the metabolic by-product of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least in part, on anaerobic metabolism rather than the normal aerobic metabolism. 2. This is a moderate base deficit and indicates buildup of lactic acidosis resulting from impaired tissue oxygenation. 3. Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues. 4. Low mucosal pH indicates development of acidosis. 5. This is a normal arterial pH.

A patient has been admitted to the emergency department with bleeding from a traumatic amputation of the leg. Which findings would the nurse interpret as indicating this patient's blood loss is severe? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Heart rate is 120. 2. Blood has soaked the dressing applied by first responders. 3. Blood pressure is 78/50. 4. Mild anxiety is present. 5. Respiratory rate is 29 breaths/min.

Answer: 1, 3 Explanation: 1. Marked tachycardia, greater than 110 beats/min, indicates severe volume loss. 2. It is not possible to characterize blood loss by the appearance of a bandage. Blood may have been lost prior to the application of the bandage. 3. Marked hypotension indicates severe blood loss. 4. Presence of mild anxiety indicates moderate hypovolemia. 5. Respiratory rate is mildly elevated in moderate blood loss.

A patient who sustained a gunshot wound walks into the emergency department and collapses. Which priority directions should the nurse who assumes this patient's care give to those coming to assist? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check the airway. 2. Bring a wheelchair. 3. Put direct pressure on the wound. 4. Check for identification. 5. Check the pulse.

Answer: 1, 3, 5 Explanation: 1. Airway patency is the most important intervention for this patient. 2. This patient will likely need to be transported by stretcher. 3. Controlling the source of the fluid loss is imperative. 4. Checking for identification can wait until more pertinent interventions are performed. 5. The patient may have collapsed due to cardiac arrest from hypovolemia. Checking the pulse is part of the immediate assessment.

The nurse is monitoring a patient at risk for development of left ventricular failure and cardiogenic shock. Which findings would the nurse immediately discuss with the primary healthcare provider? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Development of an S3 heart sound 2. Sustained systolic hypertension 3. Development of bilateral crackles 4. Decrease in pulmonary arterial wedge pressure (PAWP) 5. Decrease in cardiac index

Answer: 1, 3, 5 Explanation: 1. Development of third or fourth heart sounds may indicate development of left ventricular failure. 2. Sustained systolic hypotension would indicate development of left ventricular failure. 3. Increased pulmonary congestion, as manifested by development of bilateral crackles, may indicate that left ventricular failure is developing. 4. Left ventricular failure would be manifested by elevation of PAWP. 5. Low cardiac index can indicate development of left ventricular failure.

A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate? 1. Decreasing the amount of oxygen being given 2. Immediate initiation of fluid resuscitation 3. Repeat of the testing in 4 hours 4. Bedside fingerstick level of blood glucose

Answer: 2 Explanation: 1. An increased serum lactate calls for increased oxygenation. 2. A lactate level greater than 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation. 3. There is no need to repeat this test before intervening. 4. Measuring blood glucose is not indicated by this lab result.

A patient is admitted to the emergency department with severe burn injuries. The nurse's priority actions are to prevent development of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive

Answer: 2 Explanation: 1. Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock. 2. Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority. 3. Distributive shock, particularly septic shock, is a potential complication for patients with burn injury, and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care. 4. Depending on other injuries, the patient with burns may develop obstructive shock, but this is not the nurse's highest priority in emergent care.

The nurse is evaluating a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement? 1. Temperature of 97.8°F 2. Heart rate of 70 beats/min 3. Resistance to ventilator-assisted breaths 4. Pink tone to the skin

Answer: 2 Explanation: 1. Hypothermia is one of the triad of expected signs of neurogenic shock. This patient remains hypothermic. 2. Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement. 3. Respiratory rate is not one of the triad of expected findings associated with neurogenic shock. The patient may be mechanically ventilated, but a change in acceptance of this assistance is not indicative of an improved shock status. 4. Peripheral vasodilation produces a pink skin tone, so this finding does not indicate improvement.

A patient admitted to the emergency department following chest trauma has tracheal deviation to the left. The nurse would prepare for which emergency medical intervention? 1. Open thoracotomy 2. Placement of a chest tube 3. Open excision of the pericardial sac 4. Immediate cardiopulmonary resuscitation

Answer: 2 Explanation: 1. Open thoracotomy is not indicated for this complication. 2. Tracheal deviation can result from mediastinal shifting due to a tension pneumothorax. Treatment is placement of a chest tube or a needle thoracostomy. 3. Excision of the pericardial sac may be indicated when cardiac tamponade exists. There is no indication that this complication has developed. 4. There is no indication that cardiopulmonary resuscitation is needed at this point.

A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury. Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome (MODS)? 1. Urine output less than 400 mL/day 2. Decreased PaO2 with an increase in FiO2 3. Alteration in level of consciousness 4. Hypotension that responds to fluids

Answer: 2 Explanation: 1. Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome. 2. Decreased PaO2 with an increase in FiO2 is correct because the lungs are usually the first organs to show signs of dysfunction and is the main organ affected in multiple organ dysfunction syndrome. 3. Alteration in level of consciousness is probably already present with the closed head injury, and it also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia and not necessarily progress to multiple organ dysfunction syndrome. 4. The hypotension and dysrhythmias common in MODS do not respond to fluid therapy.

A nurse is providing care to a patient with progressive shock. Which patient problem is characteristic of this stage and is priority in guiding the selection of interventions for this patient? 1. The patient's airway is often compromised. 2. Perfusion of oxygen and nutrients to tissues is insufficient. 3. The patient experiences maximal physiologic and psychologic stress in this stage. 4. Skin integrity continues to be impaired.

Answer: 2 Explanation: 1. Without additional assessment findings, it is not possible to determine if this patient's airway is compromised. 2. Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority problem for all patients in shock. 3. Undoubtedly this patient is experiencing stress, but this is not the highest priority problem. 4. This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination.

A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Persistent hypotension 2. Heart rate 118 3. Development of a bundle branch block 4. Drop in urine output 5. Mottling of extremities

Answer: 2, 3, 4, 5 Explanation: 1. The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough of the drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring. 2. Tachycardia can be an adverse effect of dopamine. 3. Aberrant cardiac conduction may indicate an adverse drug effect is occurring. 4. Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidneys will cause decrease in urine output. 5. Mottling of extremities indicates peripheral ischemia.

An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurse's priority intervention? 1. Benadryl (diphenhydramine) 50 mg intravenously 2. Oxygen at 3 liters via nasal cannula 3. Epinephrine 1:1000 0.5 mg sq 4. Normal saline at 150 mL/hr

Answer: 3 Explanation: 1. Administration of diphenhydramine is appropriate but is not the initial therapy. 2. Oxygen is administered according to pulse oximetry readings. 3. The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. This is the priority intervention. 4. After experiencing anaphylaxis, the patient will likely be hospitalized and given IV fluids. This is not the immediate priority.

A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive? 1. The patient complains of a severe headache. 2. The patient's urine output has dropped. 3. The patient begins to shiver. 4. The patient develops a cough.

Answer: 3 Explanation: 1. Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia. 2. Decreased urine output is not associated with treatment for hyperthermia. 3. Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified. 4. Development of a cough is not associated with treatment for hyperthermia.

A patient was admitted to the emergency department for treatment of a severe infection. Which traditional assessment would raise the nurse's concern that this patient may be developing shock? 1. Hot, dry skin 2. Respiratory rate 11 3. Pulse rate 118 and weak 4. Anxiety

Answer: 3 Explanation: 1. Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection. 2. Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system. 3. Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues. Weak pulses occur as the contractility of the heart decreases. 4. Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state.

A patient is in the intensive care unit with multiple organ dysfunction syndrome. Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system? 1. Increased flatus 2. Abdominal cramps 3. Absent bowel sounds 4. Complaint of epigastric burning

Answer: 3 Explanation: 1. Increased flatus would indicate some degree of gastrointestinal functioning. 2. Abdominal cramps would indicate some degree of gastrointestinal functioning. 3. Because there is no objective measure of gastrointestinal function in the patient, the one assessment finding that could indicate dysfunction in this system would be the development of an ileus, which can be associated with the absence of normal bowel sounds. 4. Complaint of epigastric burning is not specific to gastrointestinal dysfunction.

A patient who had a myocardial infarction this morning is now developing cardiogenic shock. Which nursing intervention is indicated? 1. Increase IV fluids. 2. Administer vasoconstricting drugs. 3. Provide care in a calm, reassuring manner. 4. Withhold oral fluids and nutrition.

Answer: 3 Explanation: 1. Increasing IV fluids is not indicated when the patient's heart is already damaged. The physiological issue is not lack of fluid, but inability to pump fluid efficiently. 2. It is more likely that vasodilating drugs like nitroglycerin will be administered. 3. Providing care in a calm and quiet manner helps to decrease the patient's anxiety, thereby reducing oxygen consumption. 4. There is no reason to withhold oral fluids and nutrition that is evidenced by this scenario. If the patient appears to be deteriorating rapidly, withholding food may be indicated.

A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis. The patient's wife says, I thought he didn't have any infection. How should the nurse respond? 1. He probably had an infection that we did not recognize. 2. He developed SIRS after getting multiple organ dysfunction syndrome. 3. Infection isn't necessary to develop SIRS, only a severe inflammation. 4. Your husband's body is working against itself.

Answer: 3 Explanation: 1. SIRS can occur in the absence of infection. 2. Multiple organ dysfunction syndrome follows SIRS. 3. Pancreatitis is a severe inflammatory illness. SIRS can develop without infection. 4. A general statement like this is not an adequate explanation.

A patient admitted with an infected wound is demonstrating signs of improvement. The nurse would attribute this improvement to which physiologic process? 1. Cortisol released from the adrenal glands 2. Hypothalamus activating white blood cells 3. Endothelial cells releasing mediators to contain the infection 4. Mediators that decrease permeability of vessel walls

Answer: 3 Explanation: 1. The wound infection was not contained because of the release of cortisol by the adrenal glands. 2. The hypothalamus does not activate white blood cells. 3. Mediators, bioactive substances that stimulate physiologic changes in cells, are released from endothelial cells. It is these mediators that control inflammation, activate coagulation, deposit fibrin, and inhibit fibrinolysis to contain the inflammatory activity to the site of the infection. 4. Permeability of the vessel walls is increased in order to contain infection.

A patient with cardiac decompensation is started on dobutamine at 1 mcg/kg/min with an order to titrate to effect. After receiving this dose for several minutes, the patient develops tachycardia and occasional premature ventricular contractions. What nursing intervention is indicated? 1. Increase the dose to 1.5 mcg/kg/min. 2. Discontinue the infusion. 3. Decrease the infusion to 0.5 mcg/kg/min. 4. Contact the prescriber immediately.

Answer: 3 Explanation: 1. There is no indication to increase the dose. 2. Discontinuing the infusion is not the first intervention. 3. Decreasing the infusion rate may reverse these adverse cardiac effects. 4. The order is given to titrate the drug to effect. There is no reason to contact the prescriber at this point.

A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention? 1. Stop the infusion, but leave normal saline infusing at a rate to keep the vein open. 2. Stop the infusion and place an intermittent infusion cap on the IV access device. 3. Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion. 4. Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patient's response.

Answer: 4 Explanation: 1. Abrupt withdrawal of this medication is not indicated. 2. Abrupt withdrawal of this drug is not indicated. 3. The infusion rate should not be abruptly lowered. 4. The nurse should decrease the infusion slowly, while monitoring the patient's response. This is the only response that does not result in abrupt withdrawal of the medication.

A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock? 1. Cold extremities 2. Increase in serum lactate levels 3. Decreased SCVO2 4. Widening of pulse pressure

Answer: 4 Explanation: 1. Cold and mottled extremities are associated with later stages of septic shock. 2. Increased serum lactate levels indicate a later stage of shock. 3. Decreased SCVO2 indicates a later stage of shock. 4. Since the patient's diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock.

The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome (SIRS). Which assessment findings would increase the patient's risk of developing this syndrome? 1. Age 36 2. Body mass index of 23 3. Asian ancestry 4. History of Crohn's disease

Answer: 4 Explanation: 1. Patient-related risk factors for developing systemic inflammatory response syndrome include older age. 2. A normal body mass index does not increase risk for SIRS. 3. There is no indication that those of Asian ancestry are at higher risk of developing SIRS. 4. Compromised gut integrity, such as is seen in Crohn's disease, is a risk factor for the development of SIRS.

A patient tells the nurse that he is upset because his surgical wound is infected, and everyone else that he knows who had the same surgery did not have the same problem. How should the nurse respond to this concern? 1. There really is nothing that could be done to prevent it. 2. You should talk to your surgeon about your concerns. 3. At least you are in the hospital when the infection started and not at home. 4. Developing an infection depends on many factors, even things like age and gender.

Answer: 4 Explanation: 1. The nurse has no way of knowing if there was a way to prevent this patient's infection. 2. The nurse can offer some explanation about the development of infection instead of referring the patient to the surgeon. 3. Commenting about being in the hospital instead of home when the infection developed does not address the patient's concerns. 4. How endothelial cells respond to alterations in the environment differ, according to the host genetics, age, gender, nature of the pathogen, and location of the vascular bed. The nurse should explain to the patient that the development of a wound infection depends on these variables.

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? A. A slow and imperceptible pulse B. A rapid, bounding pulse C. A weak and thready pulse D. A slow but steady pulse

B. A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? A. Brachial artery B. Aorta C. Right ventricular wall D. Radial artery

B. Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall.

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? A. Stevens-Johnson syndrome from the administration of antibiotics B. Disseminated intravascular coagulation (DIC) C. Septicemia D. Stress ulcer

B. Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (e.g., prothrombin time [PT], activated partial thromboplastin time [aPTT]) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. The other conditions listed would not result in bleeding simultaneously at multiple sites.

A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels? A. cardiogenic B. distributive C. organ failure D. hypovolemic

B. Distributive shock results from displacement of blood volume, creating pooling of blood in the peripheral blood vessels. Cardiogenic shock results from the failure of a heart as a pump. With hypovolemic shock, there is a decrease in the intravascular volume. Organ failure is not a type of shock.

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

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

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? A. Hemoglobin: 14.2 g/dL B. WBC: 42,000/mm3 C. ESR: 19 mm/hour D. Potassium: 4.8 mEq/L

B. Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

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

B. The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.

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. Semi-Fowler's B. Modified Trendelenburg C. Trendelenburg D. Supine

B. 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.

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

B. The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

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

C. Adrenergic drugs are the main medications used to treat shock due to their action on the receptors of the sympathetic nervous system.

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? A. Administration of oxygen via venturi mask B. Thoracotomy with chest tube insertion C. Intubation and mechanical ventilation D. Pericardiocentesis

C. Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Pericardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm? A. Prednisone B. Proventil C. Epinephrine D. Benadryl

C. Epinephrine is given for its vasoconstrictive actions, as well as for its rapid effect of reducing bronchospasm. Benadryl and Proventil (nebulized) are given to reverse the effects of histamine. Prednisone is given to reduce inflammation, if necessary.

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. A. 90 mm Hg B. 80 mm Hg C. 60 mm Hg D. 70 mm Hg

C. Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? A. Avoid heavy meals. B. Arrange personal care supplies nearby. C. Maintain activity restriction to bedrest. D. Limit interaction with visitors.

C. Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? A. Normal B. Unable to measure C. Low D. High

C. The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.

The nurse, a member of the health care team in the ED, is caring for a client who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? A. Closely monitor fluid replacement therapy. B. Inform the client's family immediately that the client will likely not survive. C. Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock. D. Protect the client's airway, optimize intravascular volume, and initiate the early rehabilitation process.

C. The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the client does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the client and helping them to understand the irreversible stage of shock is the best intervention. Informing the client's family too early that the client will not survive would rob the family of hope and interrupt the grieving process. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing end-of-life issues.

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? A. Carcinogenic B. Hypovolemic C. Distributive D. Obstructive

C. Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such condition as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is A. An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection B. A young female adolescent who developed shock from tampon use during menses C. A middle-aged woman with metastatic breast cancer and a BMI of 26 D. An older adult man with end-stage renal disease and an infected dialysis access site

D. MODS may develop when a client experiences septic shock. Those at increased risk for MODS are older clients, clients who are malnourished, and clients with coexisting disease.

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? A. Liver B. Kidneys C. Lungs D. Brain

D. The body displays a fight-or-flight response, with the release of catecholamines. Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.

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

D. The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

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

D. When administering large volumes of fluid replacement, the nurse monitors the client for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. The nurse assesses for jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. The client should exhibit vesicular breath sounds.

When vasoactive medications are administered, the nurse must monitor vital signs at least how often? A. 30 minutes B. Hourly C. 45 minutes D. 15 minutes

D. When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? A. hypovolemic shock B. anaphylactic shock C. septic shock D. neurogenic shock

Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections. Anaphylactic shock is a subcategory of distributive shock, but it is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive, such as bee venom, latex, fish, nuts, and penicillin. Hypovolemic shock is not a subcategory of distributive shock. It occurs when the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma.