Disaster and Shock
ANS: D Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.
10. The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock? a. "Is your blood pressure higher than usual?" b. "Are you having pain in your throat?" c. "Have you been vomiting?" d. "Are you usually this swollen?"
ANS: A Therapy during the second (late) phase of septic shock is aimed at enhancing the blood's ability to clot. Enoxaparin would increase the client's risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client's blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.
16. The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question? a. Enoxaparin (Lovenox) 40 mg subcutaneous twice daily b. Transfusion of 2 units of fresh frozen plasma c. Regular insulin intravenous drip per protocol d. Cefazolin (Ancef) 1 g IV every 6 hours
In a multiple-trauma victim, which assessment finding signals the most serious and life-threatening condition? A. A deviated trachea B. Gross deformity in a lower extremity C. Decreased bowel sounds D. Hematuria
A. A deviated trachea is a symptoms of tension pneumothorax. All of the other symptoms need to be addressed, but are of lesser priority.
A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? a. High urgent b. Urgent c. Non-urgent d. Emergent
Answer: D - Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones).Non-urgent conditions can wait for hours or even days. (High urgent is not commonly used; however, in5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the timelapsing prior to treatment).
A patient who is in cardiogenic shock has a urine output of 20mL/hr. When further assessing the patient's renal function, what additional findings are anticipated? Select all that apply. A. Decreased urine specific gravity B. Increased blood urea nitrogen (BUN) C. Decreased urine sodium D. Decreased serum creatinine
B Increased BUN C. Decreased urine sodium
Hemorrhagic fever (There is no established treatment for most viruses that cause hemorrhagic fever. Plague, anthrax, and tularemia are effectively treated with antibiotics if there is a sufficient supply of the antibiotics and the organisms are not resistant to them.)
Which agent of terrorism does not have an established treatment for those exposed to it? a. Plague b. Anthrax c. Tularemia d. Hemorrhagic fever
After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? a. Are you sure no more victims are coming into the ED? b. Do all areas of the hospital have the supplies and personnel they need? c. Have all ED staff had the chance to eat and rest recently? d. Does the Chief Medical Officer agree this disaster is under control?
b. Do all areas of the hospital have the supplies and personnel they need?
A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care.
c. In a disaster, extensive resources are not used for one person at the expense of many others.
Which of the following assessment findings is an early indication of hypovolemic shock? a.) Diminished bowel sounds b.) Increased urinary output c.) Tachycardia d.) Hypertension
c.) Tachycardia Rationale: Tachycardia is an early symptom as the body compensates for a declining blood pressure the heart rate increases to circulate the blood faster to prevent tissue hypoxia.
An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
ANS: A, C, E Septic shock manifests with decreased cardiac output, increased blood glucose, and increased serum lactate. The other parameters do not correlate with septic shock.
3. A client has septic shock. Which hemodynamic parameters does the nurse correlate with this type of shock? (Select all that apply.) a. Decreased cardiac output b. Increased cardiac output c. Increased blood glucose d. Decreased blood glucose e. Increased serum lactate f. Decreased serum lactate
ANS: B Ringer's lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as a buffer in the presence of acidosis. The other solutions do not contain any substance that would buffer or correct the client's acidosis.
5. A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer? a. Normal saline b. Ringer's lactate c. 5% dextrose in water d. 5% dextrose in 0.45% normal saline
Which type of shock is associated with low blood levels? A. Hypovolemic shock B. Septic shock C. Anaphylactic shock D. Cardiogenic shock
A. Hypovolemic Shock
The nurse is preparing to administer Lactate Ringer's to a client with hypovolemic shock. Which intervention is important in helping to stabilize the client's condition? A. Warming the intravenous fluids B. Determining whether the client can take oral fluids C. Checking for the strength of pedal pulses D. Obtaining the specific gravity of the urine
A. Warming the intravenous fluids
When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of a. blood. b. vaccine. c. atropine. d. antibiotics.
B Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a- Increased serum albumin b- Decreased respiratory compliance c- Increased gastrointestinal (GI) motility d- Decreased blood urea nitrogen (BUN)/creatinine ratio
B- Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.
What is the treatment of choice to correct Hypovolemic Shock? A. Have the patient drink a large bottle of Gatorade. B. Replace fluids intravenously as quickly as possible. C. Administer a vasopressor D. All of the above.
B. Replace fluids intravenously as quickly as possible
A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120 beats/minute, blood pressure 80/55 and urine output 20ml/hr. After administering an IV fluid bolus, which of these signs if noted by the healthcare provider is the best indication of improved perfusion? A. Right atrial pressure increases B. Systolic blood pressure increases to 85 C. Urine output increases to 30ml/hr D. Heart rate drops to 100 beats/minute
C. Urine output increases to 30ml/hr
A massive gastrointestinal bleed has resulted in hypovolemic shock in a patient. What is a priority nursing diagnosis? A. Acute pain B. Impaired tissue integrity C. Decreased cardiac output D. Ineffective tissue perfusion
D
What laboratory finding fits with a medical diagnosis of cardiogenic shock? A. Decreased liver enzymes B. Increased white blood cells C. Decreased red blood cells, hemoglobin, and hematocrit D. Increased blood urea nitrogen (BUN) and serum creatinine levels
D
What laboratory finding fits with a medical diagnosis of cardiogenic shock? a-Decreased liver enzymes b-Increased white blood cells c-Decreased red blood cells, hemoglobin, and hematocrit d-Increased blood urea nitrogen (BUN) and serum creatinine levels
D- The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.
A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock? A. Hypertension. B. Bradycardia. C. Bounding pulse. D. Confusion.
D. Confusion Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate
The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? A. Slow the IV infusion rate B. Administer dopamine C. No interventions are needed at this time D. Increase the IV infusion rate
D. Increase the IV infusion rate
What class of drug is typically used to treat neurogenic shock? A. Beta-blocker B. Calcium-channel blocker C. Loop diuretic D. Vasopressor
D. Vasporessor
I'm no longer able to breathe on my own, my HR is erractic or I've gone in to asystole, my skin has become jaundiced, I'm anuric, become unresponsive and now have profound acidosis. What stage of shock
End-Organ
My BP systolic BP <80-90, HR 100-150, rapid shallow respirations with crackles heard on auscultation, skin has become mottled with petechiae, urine output has become severely decreased, I'm lethargic and have gone in to metabolic acidosis. What stage of shock
Shock
Nursing assessment of a client receiving serum albumin for treatment of shock should include: a.) Assessing lung sounds. b.) Monitoring glucose. c.) Monitoring the potassium level. d.) Monitoring hemoglobin and hematocrit.
a.) Assessing lung sounds. Rationale: Colloids pull fluid into vascular space. Circulatory overload could occur. The nurse should assess the client for symptoms of heart failure.
The client experiences shock following a spinal cord injury. This type of shock is classified as: a.) Hypovolemic. b.) Neurogenic. c.) Cardiogenic. d.) Anaphylactic.
a.) Neurogenic.
A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care
b. Client who had open reduction and internal fixation of a femur fracture 3 days ago e. Client on the medical unit for wound care
A client is progressing into the third stage of shock. The nurse will expect this client to demonstrate: Choose all that apply: a.) Intractable circulatory failure. b.) Neuroendocrine responses. c.) Demonstrating MODS. d.) Buildup of metabolic wastes. e.) Profound hypotension. f.) Increase in lactic acidosis.
c.) Demonstrating MODS. d.) Buildup of metabolic wastes.
ANS: A The client at risk for septic shock should be instructed to clean his or her toothbrush daily, either by running it through the dishwasher or by rinsing it in laundry bleach. Clients should be instructed to bathe daily and wash the armpits, the groin, and the rectal area. The client should refrain from cleaning pet litter boxes. Clients recovering from septic shock are not at higher risk for bleeding disorders.
18. A client recovering from septic shock is preparing for discharge home. What priority information does the nurse include in the teaching plan for this client? a. "Clean your toothbrush with laundry bleach daily." b. "Bathe every other day with antimicrobial soap." c. "Wash your hands after changing pet litter boxes." d. "Use an electric razor when you shave your face."
ANS: A A decrease in urine output is a sensitive indicator of early shock. In severe shock, urine output is decreased (compared with fluid intake) or even absent. Alterations in temperature, irregular rhythms, and changes in bowel movements are not early signs of shock.
21. The nurse is planning discharge education for a client who had an exploratory laparotomy. Which nursing statement is appropriate when teaching the client to monitor for early signs of shock? a. "Monitor how much urine you void and report a decrease in the amount." b. "Take your temperature daily and report any below-normal body temperatures." c. "Assess your radial pulse every day and report an irregular rhythm." d. "Monitor your bowel movements and report ongoing constipation or diarrhea."
When caring for a patient in acute septic shock, what should the nurse anticipate? A. Infusing large amounts of IV fluids B. Administering osmotic and/or loop diuretics C. Administering IV diphenhydramine (Benadryl) D. Assisting with insertion of a ventricular assist device (VAD)
A
The following actions are part of the routine emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patient's rings. b. Place ice packs on both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 100 mg PO.
A The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewelry.
the hospital's emergency response plan
A chemical explosion occurs at a nearby industrial site. The first responders report that victims are being decontaminated at the scene and approximately 125 workers will need medical evaluation and care. The nurse receiving this report should know that this will first require activation of a. a code blue alert b. a disaster medical assistance team c. the local police and fire department d. the hospital's emergency response plan
When caring for a patient in acute septic shock, what should the nurse anticipate? a- Infusing large amounts of IV fluids b- Administering osmotic and/or loop diuretics c- Administering IV diphenhydramine (Benadryl) d- Assisting with insertion of a ventricular assist device (VAD)
A- Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock.
The nurse is triaging four clients injured in a train derailment. Which client should receive priority treatment? A 42-year-old with dyspnea and chest asymmetry b 17-year-old with a fractured arm C 4-year-old with facial lacerations D.A 30-year-old with blunt abdominal trauma
Answer A is correct. Following the ABCDs of basic emergency care, the client withdyspnea and asymmetrical chest should be cared for first because thesesymptoms are associated with flail chest. Answer D is incorrect because he shouldbe cared for second because of the likelihood of organ damage and bleeding.Answer B is incorrect because he should be cared for after the client withabdominal trauma. Answer C is incorrect because he should receive care lastbecause his injuries are less severe
You are working in the triage area of an ED, and four patients approach the triage desk at the sametime. List the order in which you will assess these patients. a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting
Answer: B, A, D, C - An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24-48 hours if necessary
A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98, heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40. The healthcare provider suspects which type of shock? A. Cardiogenic B. Hypovolemic C. Neurogenic D. Distributive
B. Hypovolemic
You are assigned to telephone triage. A patient who was stung by a common honey bee calls for advice, reports pain and localized swelling, but denies any respiratory distress or other systemic signs of anaphylaxis. What is the action that you should direct the caller to perform? A. Call 911. B. Remove the stinger by scraping. C. Apply a cool compress. D. Take an oral antihistamine
B. The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance.
The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment? a. A patient with absent pedal pulses b. A patient with an open femur fracture c. A patient with a sucking chest wound d. A patient with bleeding of facial lacerations
C Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems.
A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? a-Insulin infusion b- IV administration of epinephrine c- Aggressive IV crystalloid fluid resuscitation d- Administration of nitrates and β-adrenergic blockers
C- Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).
What causes decreased BP in neurogenic shock? A. Movement of fluid into the cells B. Movement of fluid into the vasculature C. Disrupted SNS communication D. Polyuria
C. Disrupted SNS communication
The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.
Correct answer: d Rationale: Adequate tissue perfusion in a patient with multiple-organ dysfunction syndrome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.
These patients present to the ED complaining of acute abdominal pain. Prioritize them in order of severity. a. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating b. A 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days c. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week d. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour
D B C A The patient with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate suddenly. The 11-year-old boy needs evaluation to rule out appendicitis. The woman needs evaluation for gallbladder problems that appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a-Acute pain b-Impaired tissue integrity c-Decreased cardiac output d-Ineffective tissue perfusion
D- The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.
After falling from a 10' ladder, a patient is brought to the emergency department. The patient is alert, reports back pain, and difficulty moving the lower extremities. Which additional observation is an indication the patient may be experiencing neurogenic shock? A. Cool and pale skin B. Increased systolic blood pressure C. Poor skin turgor D. Bradycardia
D. Bradycardia
Supportive treatment (Because hemorrhagic fever (e.g., Marburg virus, Ebola virus) causes hemorrhage of tissues and organs, care is primarily supportive. Intramuscular injections and anticoagulants are avoided. Care of the rodent or mosquito bite, if needed, is included in supportive treatment.)
When a patient is admitted with hemorrhagic fever, what nursing treatment should be provided? a. Parenteral analgesics b. Supportive treatment c. Warfarin administration d. Care of the rodent or mosquito bite
Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: a.) Monitoring for fluid overload. b.) Monitoring for cardiac dysrhythmias. c.) Monitoring respiratory status. d.) Monitoring for hypotension.
b.) Monitoring for cardiac dysrhythmias. Rationale: Dobutamine is beneficial in cases where shock is caused by heart failure. The drug increases contractility, and has the potential to cause dysrhythmias.
The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a.) The patient is restless and anxious. b.) The patient has a heart rate of 134. c.) The patient has hypotonic bowel sounds. d.) The patient has a temperature of 94.1° F.
d.) The patient has a temperature of 94.1° F. Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a.) check the blood pressure. b.) obtain an oxygen saturation. c.) attach a cardiac monitor. d.) check level of consciousness.
b.) obtain an oxygen saturation. Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.
ANS: A Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency. Shock represents the "whole-body response," affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal of the cause of shock, resulting in death.
1. The intensive care nurse is educating the spouse of a client who is being treated for shock. The spouse states, "The doctor said she has shock. What is that?" What is the nurse's best response? a. "Shock occurs when oxygen to the body's tissues and organs is impaired." b. "Shock is a serious condition, but it is not a life-threatening emergency." c. "Shock progresses slowly and can be stopped by the body's normal compensation." d. "Shock is a condition that affects only specific body organs like the kidneys."
ANS: A Blood cultures should be obtained before IV antibiotics are started. If hypotension occurs, fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if hypotension persists.
11. A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first? a. Obtain two sets of blood cultures. b. Administer the prescribed IV vancomycin (Vancocin). c. Obtain central venous pressure (CVP) measurements. d. Administer the prescribed IV norepinephrine (Levophed).
ANS: D The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock
12. The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client's shock is caused by sepsis? a. Hypotension b. Pale clammy skin c. Anxiety and confusion d. Oozing of blood at the IV site
ANS: C Certain conditions or treatments that cause immune suppression, such as having cancer and being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a person to septic shock. The other client situations do not increase the client's risk for septic shock.
14. The nurse is assessing clients in the emergency department. Which client is at highest risk for developing septic shock? a. 25-year-old man who has irritable bowel syndrome b. 37-year-old woman who is 20% above ideal body weight c. 68-year-old woman who is being treated with chemotherapy d. 82-year-old man taking beta blockers for hypertension
ANS: A During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors. The other medications would not be prescribed during the hyperdynamic phase of septic shock.
15. The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication does the nurse expect to be prescribed? a. Heparin sodium b. Vitamin K c. Corticosteroids d. Hetastarch (Hespan)
ANS: B Administration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia. The other interventions should be completed after oxygen is administered.
17. The nurse is assessing a client at risk for shock. The client's systolic blood pressure is 20 mm Hg lower than baseline. Which intervention does the nurse perform first? a. Increase the IV fluid rate. b. Administer oxygen. c. Notify the health care provider. d. Place the client in high Fowler's position.
ANS: A Distributive shock is the type of shock that occurs when blood volume is not lost from the body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen. Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord injury, or head trauma. The other clients are at risk for hypovolemic and cardiogenic shock.
2. The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock? a. Severe head injury from a motor vehicle accident b. Diabetes insipidus from polycystic kidney disease c. Ischemic cardiomyopathy from severe coronary artery disease d. Vomiting of blood from a gastrointestinal ulcer
ANS: B Hypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting. Basketball, smoking, and traveling do not put the client at risk for hypovolemic shock.
20. The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock? a. 15-year-old adolescent who plays high school basketball b. 24-year-old computer specialist who has bulimia c. 48-year-old truck driver who has a 40-pack-year history of smoking d. 62-year-old business executive who travels frequently
ANS: A When a local infection becomes systemic, the client develops a high-grade temperature, decreased urine output, and increased respiratory rate. Because of tachycardia and low blood pressure, the client may exhibit orthostatic hypotension. This is a subtle sign of systemic infection that requires further evaluation by the health care provider. The other signs are not manifestations of complications. Warmth and redness are expected with local infection.
22. A client who has a local infection of the right forearm is being discharged. The nurse teaches the client to seek immediate medical attention if which complication occurs? a. Dizziness on changing position b. Increased urine output c. Warmth and redness at site d. Low-grade temperature
ANS: B The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus some cells are metabolizing anaerobically. Such metabolism increases the production of lactic acid, resulting in an increase in hydrogen ion production and acidosis. Other laboratory values associated with acidosis include increased creatinine (impaired renal function) and increased partial pressure of arterial carbon dioxide. Urine specific gravity is not associated with acidosis.
3. The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates that the client is at risk for acidosis? a. Decreased serum creatinine b. Increased serum lactic acid c. Increased urine specific gravity d. Decreased partial pressure of arterial carbon dioxide
ANS: C The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress. The other questions would not identify early stages of shock.
4. A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock? a. "Are you more thirsty than normal?" b. "When was the last time you urinated?" c. "What is your normal heart rate?" d. "Is your skin usually cool and pale?"
ANS: C Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation. Tachycardia is not a desired response but often occurs as a side effect.
6. The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin) drip. Which manifestation is a desired response to this medication? a. Decrease in blood pressure b. Increase in heart rate c. Increase in cardiac output d. Decrease in mean arterial pressure
ANS: C IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids. Aminoglycosides and heparin are given to clients with septic shock.
7. The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what is the priority intervention for this client? a. Administer an aminoglycoside. b. Initiate a dopamine hydrochloride (Intropin) drip. c. Administer crystalloid fluids. d. Initiate an intravenous heparin drip.
ANS: B The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and can increase shock. The nurse should monitor the client's pain, urinary output, and extremities, but these assessments do not directly relate to the nitroprusside infusion.
8. The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. Which nursing intervention is a priority when administering this medication? a. Ask if the client has chest pain every 30 minutes. b. Assess the client's blood pressure every 15 minutes. c. Monitor the client's urinary output every hour. d. Observe the client's extremities every 4 hours.
ANS: C Sodium nitroprusside (Nipride) must be protected from light to prevent degradation of the drug. It should be delivered via pump. This medication does not have any effect on respiratory rate. Hypertension is a sign of milrinone (Primacor) overdose.
9. The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which important action related to the administration of this drug does the nurse implement? a. Assess the client's respiratory rate. b. Administer the medication with gravity tubing. c. Protect the medication from light with an opaque bag. d. Monitor for hypertensive crisis.
An individual whose femoral artery has been severed and is bleeding profusely (Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a "red" designation, and a fracture would likely be deemed "yellow," urgent but not life threatening. Those not expected to survive are categorized "blue." "Black" identifies the dead.)
A mass casualty incident was identified on a nearby freeway. Which patient would likely be designated "red" during triage at the site? a. An individual who is distraught at the violence of the incident b. An individual who has experienced an open arm fracture from falling debris c. An individual who is not expected to survive a crushing head and neck wound d. An individual whose femoral artery has been severed and is bleeding profusely
The nurse provides information to a patient who was exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? A. "Anthrax can be spread by person-to-person contact." B. "It is not necessary to receive the anthrax vaccine." C. "An antibiotic will be prescribed for 2 months." D. "Antibiotics are only indicated for an active infection."
Answer: C. "An antibiotic will be prescribed for 2 months." Rationale: Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores. The patient may receive the anthrax vaccine (three doses); if vaccinated, the course of antibiotic therapy is reduced to 30 days. Antibiotics are indicated after exposure to inhaled anthrax. Ch. 69
A nurse manager educates the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse manager discuss with the staff? A. Learn the hospital emergency response plan. B. Report acts of violence to security personnel. C. Contact the American Red Cross for assistance. D. Notify local, state, and national authorities.
Answer: A. Learn the hospital emergency response plan. Rationale: All health care providers need to be prepared for a mass casualty incident; the priority responsibility is to know the agency's emergency response plan. Ch. 69
A nurse is performing triage in the emergency department. Which patient should the nurse see first? A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg. B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. C. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath. D. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg.
Answer: B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. Rationale: Patient with drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last. Ch. 69
The nurse would recognize which clinical manifestation as suggestive of sepsis? a- Sudden diuresis unrelated to drug therapy b- Hyperglycemia in the absence of diabetes c-Respiratory rate of seven breaths per minute d-Bradycardia with sudden increase in blood pressure
B- Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.
A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? a-Obtain a 12-lead ECG and arterial blood gases. b-Rapidly administer 1000 mL normal saline solution IV. c-Administer norepinephrine (Levophed) by continuous IV infusion. d-Carefully insert a nasogastric tube and an indwelling bladder catheter.
B-Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? A) Avoid elevating head of bed. B) Check temperature every 2 hours. C) Monitor breath sounds frequently. D) Assess skin for flushing and itching.
C
These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. A 72-year-old with palpitations and chest pain b. A 45-year-old complaining of 6/10 abdominal pain c. A 22-year-old with multiple fractures of the face and jaw d. A 30-year-old with a misaligned right leg with intact pulses
C, A, B, D The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 45- year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture of the right leg and should be seen soon, but this patient has the least life-threatening injury.
Which interventions should be used for anaphylactic shock (select all that apply)? a. Antibiotics b. Vasodilator c. Antihistamine d. Oxygen supplementation e. Colloid volume expansion f. Crystalloid volume expansion
C, D, E Due to the massive vasodilation, release of vasoactive mediators, and increased in capillary permeability from the immediate reaction, fluid leaks from the vascular space into the interstitial space. By administering a colloid (which contain larger particles that do not penetrate the semipermable membrane), the large particles will stay intravascularly. Due to their smaller size particle composition, a crystalloid would not stay intravascularly and leak interstitially.
The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? a-Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds b-Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin c-PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites d-Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL
C- Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.
The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? a-Antibiotics are not useful once an infection has progressed to sepsis. b-Weaning the patient away from the ventilator is the top priority in sepsis. c-Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d-The patient has recovered from sepsis if he has warm skin and ruddy cheeks.
C-Patients with sepsis may be normovolemic but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Addititonal respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.
A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of: a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.
Correct answer: b Rationale: Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temperature must be higher than 100.9° F (38.3° C), or the core temperature must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or elevated pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation.
The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a-22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident b-48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c-65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina d-82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection
D- A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.
ANS: A, B, D Heart and respiratory rates increased from the client's baseline level and a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock.
MULTIPLE RESPONSE 1. The nurse is assessing a client who is in early stages of hypovolemic shock. Which manifestations does the nurse expect? (Select all that apply.) a. Elevated heart rate b. Elevated diastolic blood pressure c. Decreased body temperature d. Elevated respiratory rate e. Decreased pulse rate
Botulism (Botulism caused by Clostridium botulinum is a lethal neurotoxin that is treated by inducing vomiting, enemas, antitoxin, and mechanical ventilation. Sarin is a colorless, odorless chemical agent of terrorism that affects the nervous system. Smallpox is from a virus and causes skin lesions. Tularemia is a bacterium that primarily infects rabbits and causes influenza-like symptoms in humans.)
Which biologic agent of terrorism is a bacterial neurotoxin that causes paralysis and respiratory failure, with death occurring within 24 hours of exposure? a. Sarin b. Botulism c. Smallpox d. Tularemia
A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag
a. A 35-year-old female with severe chest pain: red tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag
Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen
a. Partial-thickness burns covering both legs c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes f. Bruising and pain in the right lower abdomen
A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.
a. Provide water and healthy snacks for energy throughout the event.
The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents. c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone.
a. You are free to express your feelings; whatever is said here stays here.
A client in shock is prescribed an inotropic drug to act on alpha and beta receptors. The nurse will most likely be administering: a.) Dopamine. b.) Dobutamine. c.) Pavulon. d.) Milrinone.
a.) Dopamine.
A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock? a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Distributive
a.) Hypovolemic
Which type of fluid is most appropriate for volume replacement for a patient with non-hemorrhagic hypovolemic shock? a.) Lactated Ringers (LR) b.) 10% Dextrose in Water (D 10 W) c.) One-half Normal Saline (1/2% NS) d.) Packed Red Blood Cells (PRBC)
a.) Lactated Ringers (LR)
A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic Decides the number, acuity, and resource needs of clients b. Hospital incident commander Assumes overall leadership for implementing the emergency plan c. Public information officer Provides advanced life support during transportation to the hospital d. Triage officer Rapidly evaluates each client to determine priorities for treatment e. Medical command physician Serves as a liaison between the health care facility and the media
b. Hospital incident commander Assumes overall leadership for implementing the emergency plan d. Triage officer Rapidly evaluates each client to determine priorities for treatment
An intensive care nurse, is assessing a patient with suspected sepsis. Which predisposing factors would expect to be found in the patient with septic shock? a.) A 45 year old client with a history of renal insufficiency. b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection. c.) A 27 year old with pyelonephritis responding to treatment with an antibiotic. d.) A 50 year old with community acquired tuberculosis.
b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection.
A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a.) Insert two 14-gauge IV catheters. b.) Administer oxygen at 100% per non-rebreather mask. c.) Place the patient on continuous cardiac monitor. d.) Draw blood to type and crossmatch for transfusions.
b.) Administer oxygen at 100% per non-rebreather mask. Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.
A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a.) Administer all medications through the patient's indwelling central line. b.) Place the patient in a private room. c.) Restrict the patient to foods that have been well-cooked or processed. d.) Insert a nasogastric (NG) tube for enteral feeding.
b.) Place the patient in a private room. Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.
The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include: a.) pH 7.48, PaCO2 33 mm Hg. b.) pH 7.33, PaCO2 30 mm Hg. c.) pH 7.41, PaCO2 50 mm Hg. d.) pH 7.38, PaCO2 45 mm Hg.
b.) pH 7.33, PaCO2 30 mm Hg. Rationale: The patient's low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning "pH 7.48" suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning "pH 7.41" suggest compensated respiratory acidosis. The values in the answer beginning "pH 7.38" are normal.
A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation.
d Rationale: Neurogenic shock results in massive vasodilation without compensation as a result of the loss of sympathetic nervous system vasoconstrictor tone. Massive vasodilation leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and, ultimately, impaired cellular metabolism. Clinical manifestations of neurogenic shock are hypotension (from the massive vasodilation) and bradycardia (from unopposed parasympathetic stimulation).
. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath
d. Multiple fractured ribs and shortness of breath
When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize? a.) Intensity of peripheral pulses and body temperature. b.) Peripheral pulses and heart rate (HR). c.) Metabolic alkalosis and oxygen saturation. d.) Cardiac output (CO) and blood pressure (BP).
d.) Cardiac output (CO) and blood pressure (BP).
ANS: C The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client's pulse pressure is decreasing rapidly. The family should be updated appropriately.
13. A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the client's systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first? a. Insert a Foley catheter to monitor urine output closely. b. Ask the client's family to come to the hospital because death is near. c. Initiate the prescribed dobutamine (Dobutrex) intravenous drip. d. Obtain blood cultures before administering the next dose of antibiotics.
ANS: D During severe sepsis, interventions should focus on decreasing hypoxia, maintaining acid-base balance, keeping blood glucose levels as normal as possible, maintaining organ perfusion, minimizing adrenal insufficiency, and decreasing microemboli. Treatment should include administration of low-dose corticosteroids, insulin drip with blood glucose checks every 1 to 2 hours, hourly intake and output monitoring, and an increase in ventilator rate and tidal volume.
23. The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress. Which nursing intervention is most appropriate during this stage of sepsis? a. Check blood glucose levels every 4 hours. b. Monitor intake and urinary output twice each shift. c. Decrease ventilator rate and tidal volume. d. Administer prescribed low-dose corticosteroids.
ANS: A An increase in heart and respiratory rates (heart rate first) from the client's baseline and a slight increase in diastolic blood pressure may be the only objective manifestations of early shock. These findings do not correlate with other stages of shock.
24. The nurse is assessing a client who has septic shock. The following assessment data were collected: Baseline Data Today's Data Heart rate 75 beats/min 98 beats/min Blood pressure 125/65 mm Hg 128/75 mm Hg Respiratory rate 12 breaths/min 18 breaths/min Urinary output 40 mL/hr 40 mL/hr The nurse correlates these findings with which stage of shock? a. Early b. Compensatory c. Intermediate d. Refractory
A patient arrives in the emergency department after exposure to radioactive dust. Which action should the nurse take first? a. Place the patient in a shower. b. Obtain the patient's vital signs. c. Determine the type of radioactive agent. d. Obtain a baseline complete blood count.
A The initial action should be to protect staff members and decrease the patient's exposure to the radioactive agent by decontamination. The other actions can be done after the decontamination is completed.
A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client: Select all that apply: a.) Rapid shallow respirations. b.) Severe hypotension. c.) Mental status changes. d.) Elevated temperature. e.) Lactic acidosis. f.) Oliguria.
a.) Rapid shallow respirations. d.) Elevated temperature.
A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a.) The cardiac output is elevated. b.) The central venous pressure (CVP) is increased. c.) The systemic vascular resistance (SVR) is high. d.) The PAWP is high.
a.) The cardiac output is elevated. Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.
When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the a.) cardiac output is increased and the central venous pressure (CVP) is low. b.) pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low. c.) heart rate is decreased, and the systemic vascular resistance is low. d.) cardiac output is decreased and the PAWP is high.
a.) cardiac output is increased and the central venous pressure (CVP) is low. Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.
The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a.) urine output is 40 ml over the last hour. b.) hemoglobin is within normal limits. c.) CVP has decreased. d.) mean arterial pressure (MAP) is 65 mm Hg.
a.) urine output is 40 ml over the last hour. Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.
Sepsis is the most common cause of disseminated intravascular coagulation (DIC). All of the following statements concerning this life threatening complications are true except: a.) The rapidity of onset is determined by the intensity of the trigger and is related to the condition of the patient's liver, bone marrow and endothelium. b.) In the early phase, the patient may demonstrate manifestations of thrombosis and microemboli. c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock. d.) The most critical intervention for DIC is the early identification and treatment of the underlying disorder.
c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock.
To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are a.) stool guaiac and bowel sounds. b.) lung sounds and oxygenation status. c.) serum creatinine and urinary output. d.) serum bilirubin levels and skin color.
b.) lung sounds and oxygenation status. Rationale: The respiratory system is usually the FIRST system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.
A 4.5 kg infant is admitted to the pediatric intensive care unit after 33 days of watery diarrhea. The infant is diagnosed with severe dehydration. The infant's skin is mottled and turgor is poor. Capillary refill is delayed, and there is an absence of tears with crying. Which intervention should be the priority action by the healthcare provider? a.) Calculate the mean arterial pressure b.) Draw blood for a complete blood count c.) Establish vascular access d.) Take a complete set of vital signs
c.) Establish vascular access Rationale: Vascular access should be established quickly in order to replace lost volume before shock progresses.
When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a.) BP 88/56 mm Hg b.) Apical pulse 110 beats/min c.) Urine output 15 ml for 2 hours d.) Arterial oxygen saturation 90%
c.) Urine output 15 ml for 2 hours Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.
The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? a.) Slow the IV infusion rate b.) Administer dopamine c.) No interventions are needed at this time d.) Increase the IV infusion rate
d.) Increase the IV infusion rate
You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting 1. A B D C 2. B A D C 3. C D B A 4. C B A D
2. An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.
Your patient is in the progressive stage of shock. If the shock is not corrected and tissue hypoxia occurs, what would happen with the patients metabolism? A. The tissues will undergo anaerobic metabolism, creating lactic acid and lowering the tissue pH B. Vasomotor reflex of arteriolar constriction that reduces pooling of blood in the microcirculation C. Metabolism would be unaffected by the lower oxygen level for the 2-3 hours
A. The tissues will undergo anaerobic metabolism, creating lactic acid and lowering the tissue pH
Direct pressure to a deep laceration on the client's lower leg has failed to stop the bleeding. The nurse's next action should be to: A. Place a tourniquet proximal to the laceration. B. Elevate the leg above the level of the heart. C. Cover the laceration and apply an ice compress D. Apply pressure to the femoral artery
Answer B is correct. If bleeding does not subside with direct pressure, the nurseshould elevate the extremity above the level of the heart. Answers A and D aredone only if other measures are ineffective, so they are incorrect. Answer C wouldslow the bleeding but will not stop it, so it's incorrect
Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority? A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident. C. A patient with abdominal and chest pain following a large, spicy meal. D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.
Answer: C Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non-urgent.
A child is brought to the emergency room by his mother who reports the child was stung by a bee while playing in the back yard. The child has an itchy rash on the face, neck, and chest. Breathing is labored with audible wheezing. Which of these medications should the healthcare provider administer first? A. Diphenhydramine B. Albuterol C. Epinephrine D. Dopamine
C. Epinephrine
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? A. Antibiotics to treat the underlying infection. B. Corticosteroids to reduce inflammation. C. IV fluids to increase intravascular volume. D. Vasopressors to increase blood pressure.
C. IV fluids to increase intravascular volume
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis
C. Neurogenic Shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is indicated by rapid and bounding pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.
A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? A. Distributive B. Neurogenic C. Obstructive D. Cardiogenic
C. Obstructive
Which stage of shock is associated with the worsening of tissue hypoperfusion and onset of worsening circulatory and metabolic imbalances, including acidosis? A. Initial nonprogressive phase B. Developing phase C. Progressive stage D. Irreversible stage
C. Progressive Stage
Which of the following strategies is NOT effective for prevention of Lyme disease? A. Insect repellant on the skin and clothes when in a Lyme endemic area. B. Long sleeved shirts and long pants. C. Prophylactic antibiotic therapy prior to anticipated exposure to ticks. D. Careful examination of skin and hair for ticks following anticipated exposure.
C. Prophylactic antibiotic
An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for the nurse? A. Trauma team B. Triage C. Ambulatory or fast track clinic D. Pediatric medicine team
C. The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.
You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? A. An advanced practice nurse and an experienced LPN/LVN B. An experienced LPN/LVN and an inexperienced RN C. An experienced RN and an inexperienced RN D. An experienced RN and a nursing assistant
C. Triage requires at least one experienced RN. Pairing an experienced RN with inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial patient assessment or decision making. Pairing an experienced RN with a nursing assistant is the second best option, because the assistant can obtain vital signs and assist in transporting.
Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply): a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload.
Correct answers: a, c Rationale: Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device.
A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? a) a client complaining of muscle aches, a headache, and malaise b) a client who twisted her ankle when she fell while rollerblading c) a client with a minor laceration on the index finger sustained while cutting an eggplant d) a client with chest pain who states that he just ate pizza that was made with a very spicy sauce
D - In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority.
A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? A. High urgent B. Urgent C. Non-urgent D. Emergent
D. Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or even days. (High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time lapsing prior to treatment).
A patient is being treated for hemorrhagic shock secondary to multiple rib fractures and a lacerated liver. Two units of packed red blood cells have been administered. Which of these measurements is an indication the patient has received adequate volume replacement? A. Oxygen saturation 90% B. Increased serum creatinine C. Decreased right atrial pressure D. Decreased serum lactate
D. Decreased serum lactate
An infant was delivered to a mother with a diagnosis of chorioamnionitis. The infant is lethargic, tachypneic, and has an axillary temperature of 96.8. The healthcare provider suspects septic shock. Which of these assessments is an indication that this infant is compensating by increasing cardiac output? A. Active precordium B. Warm, flushed skin C. Bounding pulses D. Tachycardia
D. Tachycardia
What are characteristics of the irreversible stage of shock? A. The worsening of tissue hypoperfusion and the onset of worsening circulatory and metabolic imbalances, including acidosis B. The body tries to initiate compensatory mechanisms C. Nothing can correct the hemodynamic defect D. Tissue and cell damage is too great tissue and necrosis of the tissue will occur even if the underlying hemodynamic defect is corrected
D. Tissue and cell damage is too great; tissue and necrosis of the tissue will occur even if the underlying hemodynamic defect is corrected
My BP is normal, HR >100, RR >20, skin is cold and clammy, slight decrease to urinary output, confused, and respiratory alkalosis. What stage of shock
Pre-Shock
d,f (There are currently vaccines available to protect against the biologic events of terrorism of smallpox and some hemorrhagic fevers (ie yellow fever, argentine hemorrhagic fever). The anthrax vaccine is only used for individuals exposed to anthrax because of their job, not as protection against terrorism. There are currently vaccines in development for plague, botulism, and tularemia)
Which biologic agents of terrorism can be protected against with a vaccine? (SATA) a. Plague b. Anthrax c. Botulism d. Smallpox e. Tularemia f. Hemorrhagic fever
The client in shock is prescribed an infusion of lactated Ringer's solution. The nurse recognizes that the function of this fluid in the treatment of shock is to: a.) Replace fluid, and promote urine output. b.) Draw water into cells. c.) Draw water from cells to blood vessels. d.) Maintain vascular volume.
a.) Replace fluid, and promote urine output.
A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a.) urine output of 0.5 ml/kg/hr. b.) decreased peripheral edema. c.) decreased CVP. d.) oxygen saturation 90% or more.
a.) urine output of 0.5 ml/kg/hr. Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.
While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a.) cold, mottled extremities. b.) restlessness and apprehension. c.) a heart rate of 120 and cool, clammy skin. d.) systolic BP less than 90 mm Hg.
b.) restlessness and apprehension. Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.
The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain a.) a liter of lactated Ringer's solution. b.) 500 ml of 5% albumin. c. ) two 14-gauge IV catheters. d.) a retention catheter.
c. ) two 14-gauge IV catheters. Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient had been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, it is generally accepted that crystalloids should be used as the initial therapy for fluid resuscitation. A catheter would likely be ordered, but in the 1 minute that the nurse has to obtain supplies, the IV catheters would take priority.
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a.) Antibiotics to treat the underlying infection. b.) Corticosteroids to reduce inflammation. c.) IV fluids to increase intravascular volume. d.) Vasopressors to increase blood pressure.
c.) IV fluids to increase intravascular volume. Rationale: Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage.
When performing a physical assessment of a patient with severe sepsis, what abnormal assessment would the nurse expect to find? a.) A WBC of 8,100 despite the presence of chills. b.) A blood pressure of 100/72 with a capillary refill of <3 seconds. c.) Leucocytosis in a patient with absent bowel sounds. d.) Renal output that fluctuates according to intravenous intake.
c.) Leucocytosis in a patient with absent bowel sounds. Rationale: Leucocytosis in a patient with absent bowel sounds A white count > 12,000/mm3 and a left shift is one of the diagnostic criteria. Absent bowel sounds indicate a possible ileus. This would allow translocation of the intestinal flora into the bloodstream.
A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? a.) Distributive b.) Neurogenic c.) Obstructive d.) Cardiogenic
c.) Obstructive Rationale: Obstructive shock can be caused by anything that impedes the heart's ability to contract and pump blood around the body, as with cardiac tamponade.
Multiple organ dysfunction syndrome (MODS) develops in severe sepsis as a result of systemic inflammatory response syndrome (SIRS), disseminated intravascular coagulation and damage to the endothelium. Which of the following statements best describes the management of MODS? a.) The use of proton pump inhibitors and H2 agents to increase the pH of the stomach inhibit the development of stress ulcers, an ileus and malabsorption issues. b.) Maintaining ventilator settings that ensure a tidal volume of at least 6 mL/kg of body weight will keep the lungs from being injured by endothelial damage. c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s). d.) Much of the organ damage that occurs with MODS in the setting of severe sepsis is associated with pre-existing conditions.
c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s).
A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a.) cool, clammy skin. b.) shortness of breath. c.) heart rate of 48 beats/min d.) BP of 82/40 mm Hg.
c.) heart rate of 48 beats/min Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.
A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a.) nitroglycerine (Tridil). b.) dobutamine (Dobutrex). c.) norepinephrine (Levophed). d.) sodium nitroprusside (Nipride).
c.) norepinephrine (Levophed). Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.
A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a.) activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b.) stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d.) movement of interstitial fluid to the intravascular space, increasing renal blood flow.
c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.
