Iggy chapter 37 Shock

The nursing student takes the morning blood pressure of a postoperative patient, and the reading is 90/50 mm Hg. What does the student do next? Select all that apply. Report the reading to the primary nurse as a possible sign of hypovolemia. Assess the patient for subjective feelings of dizziness or shortness of breath. Check the patient's chart for trends in morning vital sign readings. Notify the instructor to verify the significance of the finding. Call a "code blue." Place the patient in reverse Trendelenburg position.

ABCD

Which statement about the systemic effects of shock is correct? The liver is essentially unaffected, but liver enzymes may be lower than normal. The current heart rate and blood pressure indicate the cardiac system is at baseline. The brain and neurologic system can withstand 10-15 minutes of severe hypoperfusion. The kidneys can tolerate hypoxia and anoxia for up to 1 hour without permanent damage.

D

A client with hypovolemic shock has these vital signs: temperature 97.9°F (36.6°C); pulse 122 beats/min; blood pressure 86/48 mm Hg; respirations 24 breaths/min; urine output 20 mL for last 2 hours; skin cool and clammy. Which prescription order for this client does the nurse question? Dopamine (Intropin) 12 mcg/kg/min Dobutamine (Dobutrex) 5 mcg/kg/min Plasmanate 1 unit Bumetanide (Bumex) 1 mg IV

DD

The nurse finds a patient on the bathroom floor. There is a large amount of blood on the floor and on the patient's hospital gown. Which actions must the nurse take? Select all that apply. Elevate the patient's legs. Establish large-bore IV access. Look for the source of the bleeding. Ensure a patent airway. Apply direct pressure to the bleeding site if possible. Check vital signs at least every 30 minutes.

ABCDE

The nurse is caring for a patient with septic shock. Which therapy specific to the management of septic shock for this patient does the nurse anticipate will be used? Inotropics Antibiotics Colloids Antidysrhythmics

B

The nurse is caring for a postoperative patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock? Pulse pressure of 40 mm Hg A rapid, weak, thready pulse Warm, flushed skin Increased urinary output

B

A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95°F (35°C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? Broad-spectrum antibiotics Blood transfusion Cooling baths NPO status

A

A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? Temperature Pulse Respiration BP

A

A client thought to be at risk for distributive shock is given a drug that constricts blood vessels. What effect does the nurse expect the drug to have on my client's mean arterial pressure (MAP)? Increased MAP without a change in vascular volume Increased MAP by increasing vascular volume Decreased MAp from widespread capillary leak Decreased MAP by decreasing vascular volume

A

Assessment findings of a patient with trauma injuries reveal cool and pale skin, reported thirst, urine output 100 mL/8 hr, blood pressure 122/78 mm Hg, pulse 102 beats/ min, and respirations 24/min with decreased breath sounds. The nurse recognizes that the patient is in which phase of shock? Nonprogressive Progressive Refractory Multiple organ dysfunction

A

The client with which laboratory result is at risk for hemorrhagic shock? International normalized ratio (INR) 7.9 Partial thromboplastin time (PTT) 12.5 seconds Platelets 170,000/mm3 (170 × 109/L) Hemoglobin 8.2 g/dL (82 mmol/L)

A

The client with which problem is at highest risk for hypovolemic shock? Esophageal varices Kidney failure Arthritis and daily acetaminophen use Kidney stone

A

The nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations are markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

A

The nurse is caring for a patient with sepsis. What is a late clinical manifestation of shock? Decrease in blood pressure MAP is decreased by less than 10 mm Hg Tachycardia with a bounding pulse Increased urine output

A

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information:Physical Assessment FindingsDiagnostic FindingsPulse 140 beats/min and threadyABG respiratory acidosisBlood pressure 60/40 mm HgLactate level 63 mg/dL(7 mmol/L)Respirations 40/min and shallowAll of these provider prescriptions are given for the client. Which does the nurse carry out first? Notify anesthesia for endotracheal intubation. Give Plasmanate 1 unit now Give normal saline solution 250 mL/hr. Type and crossmatch for 4 units of packed red blood cells (PRBCs).

A

The unlicensed assistive personnel (UAP) is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do? Compare these vital signs with the last several readings. Request that the surgeon see the client. Increase the rate of intravenous fluids. Reassess vital signs using different equipment.

A

The unlicensed assistive personnel (UAP) working under supervision of an RN is checking vital signs on the patient at risk for hypovolemic shock. Which instruction must the nurse give the UAP? Report any increase in heart rate because it is an early sign of shock. Report any increased systolic pressure, which is an early sign of shock. Report any changes in body temperature, which may indicate sepsis. Report any increase in respiratory rate because of acid-base changes.

A

What factor increases an older adult's risk for distributive (septic) shock? Reduced skin integrity Diuretic therapy Cardiomyopathy Musculoskeletal weakness

A

Which change in the skin is an early indication of hypovolemic shock? Pallor or cyanosis in the mucous membranes Color changes in the trunk area Axilla and groin feel moist or clammy Generalized mottling of skin

A

Which laboratory value indicates the beginning of severe sepsis even before other symptoms are evident? Decreased level of activated protein C Decreased serum potassium level Increased hemoglobin level Increased aPT level

A

Which medical-surgical concept has the highest priority when a patient develops shock? Perfusion Fluid and electrolyte balance Tissue integrity Cellular regulation

A

Which statement about assessment of skin during shock is accurate? For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes. For all patients in shock, the skin is expected to feel warm and dry to the touch. For a lighter skinned patient, skin is usually a whitish blue color. For a patient with dark skin, the color will be bluish gray.

A

The home health nurse is visiting a frail older adult patient at risk for sepsis because of failure to thrive and immunosuppression. What does the nurse assess this patient for? Select all that apply. Signs of skin breakdown and presence of redness or swelling Cough or any other symptoms of a cold or the flu Appearance and odor of urine, and pain or burning during urination Patient's and family's understanding of isolation precautions Availability and type of facilities for handwashing General cleanliness of the patient's home

ABCEF

A patient with hypovolemia is restless and anxious. The skin is cool and pale, pulse is thready at a rate of 135 beats/min, blood pressure is 92/50 mm Hg, and respirations are 32/min. What actions must the nurse take?Select all that apply. Obtain a stat order for an IV normal saline bolus. Check vital signs at least every 15 minutes. Notify the Rapid Response Team. Place the patient in a semi-Fowler's position. Call a "code blue" Administer supplemental oxygen.

ABCF

A young woman comes to the emergency department (ED) with lightheadedness and "'a feeling of impending doom" Pulse is 110 beats/ min; respirations are 30/min; and blood pressure is 140/90 mm Hg. Which factors does the nurse ask about that could contribute to shock? Select all that apply. Recent accident or trauma Prolonged diarrhea or vomiting History of depression or anxiety Possibility of pregnancy Use of over-the-counter medications Recent hospitalization

ABDE

The nurse identifies signs and symptoms of internal hemorrhage in a postoperative patient. What is included in the care of this patient for hypovolemic shock? Select all that apply. Elevate the feet with the head flat or elevated 30 degrees. Monitor vital signs every 5 minutes until they are stable Administer clotting factors or plasma. Provide oxygen therapy. Ensure IV access. Leave the patient and notify the Rapid Response Team.

ABDE

A patient with hypovolemic shock is receiving an infusion of dopamine. Which nursing interventions are essential when a patient is receiving this drug? Select all that apply. Take the blood pressure at least every 15 minutes. Monitor urine output every hour. Cover the infusion bag to protect it from light. Assess the patient for chest pain. Check the infusion site every 30 minutes for extravasation. Ask a patient receiving this drug about headaches.

ABDEF

Which statements about shock are true? Select all that apply. Shock is a whole-body response to tissues not receiving enough oxygen. Shock is widespread abnormal cellular metabolism. Shock occurs only in the acute care setting. Shock may occur in older adults in response to urinary tract infections. Shock is mostly classified as a disease. Shock affects all body organs.

ABDF

A client who is in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which ones does the nurse attribute to ongoing compensatory mechanisms? Select all that apply. Increasing pallor Increasing thirst Increasing contusion Increasing heart rate Increasing respiratory rate Decreasing systolic blood pressure Decreasing blood pH Decreasing urine output

ABEG

'The patient has been diagnosed with sepsis. Following the sepsis resuscitation bundle, which interventions should the nurse expect within the first 3 hours? Select all that apply. Obtain serum lactate level. Begin administering vasopressor drugs. Draw blood cultures. Administer broad-spectrum antibiotics. Assist with insertion of a central venous pressure line. Immediately transfer to the intensive care unit.

ACD

The nurse is preparing a teaching session for a patient at risk for septic shock. Which topics does the nurse include in this teaching? Select all that apply. Wash hands frequently using antimicrobial soap. Avoid aspirin and aspirin-containing products. Avoid large crowds or gatherings where people might be ill. Do not share eating utensils Wash toothbrushes in a dishwasher. Take temperature once a week.

ACDE

Which questions can help guide the nurse when evaluating the mental status of a patient at risk for shock? Select all that apply. Is it necessary to repeat questions to obtain a response? Can the patient answer "yes" or "no" questions? Does the response answer the question asked? Does the patient have difficulty making word choices? Is the patient irritated or upset by the questions? How long is the patient's attention span?

ACDEF

Which patients are at risk for distributive septic shock? Select all that apply. Older adult with urinary tract infection Patient with ruptured aortic aneurysm Patient with pneumonia Patient receiving heparin therapy Older adult with sacral pressure ulcers Older adult scheduled for outpatient colonoscopy

ACE

For which indications would the nurse be prepared to administer a colloid product? Select all that apply. Hemorrhagic shock Dehydration Peripheral tissue hypoxia Fluid replacement Restore osmotic pressure Increased H&H

ACEF

The patient has decreased oxygenation and impaired tissue perfusion. Which clinical manifestations are evidence of onset of the nonprogressive or compensatory stages of shock? Select all that apply. Decreased urine output Low-grade fever Narrowing pulse pressure Decreased heart rate Increased heart rate Increased sodium reabsorption

ACEF

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Ask family members to stay with the client. Call HCP Increase IV and oxygen rates. Remain with the client. Reassure the client that everything is being done for him or her.

ADE

Which clients are at immediate risk for hypovolemic shock? Unrestrained client in a motor vehicle collision (MVC) Construction worker Athlete Surgical intensive care unit (SICU) client 85-year-old with gastrointestinal (GI) virus

ADE

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? Hourly urine output 10 to 12 mL/hr Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg Blood glucose 245 mg/dL (13.6 mmol/L) Serum creatinine 3.6 mg/dL (318 mmol/L)

B

A patient has a systemic infection with a fever, increased respiratory rate, and change in mental status. Which laboratory values does the nurse seek out that are considered "hallmarks" of sepsis? Increased white blood count and increased glucose level Increased serum lactate level and rising band neutrophils Increased oxygen saturation and decreased clotting times Decreased white blood count with increased hematocrit

B

A patient is in hypovolemic shock related to hemorrhage from a large gunshot wound. Which order must the nurse question? Establish a large-bore peripheral IV and give crystalloid bolus. Give furosemide (Lasix) 20 mg slow IVp Insert a Foley catheter and monitor intake and output. Give high-flow oxygen via mask at 10 L/min.

B

A patient is showing early clinical manifestations of hypovolemic shock. The health care provider orders an arterial blood gas (ABG). Which ABG values does the nurse expect to see in hypovolemic shock? Increased pH with decreased PaO2, and increased Paco2 Decreased pH with decreased PaO2 and increased Paco2 Normal pH with decreased PaO2 and normal Paco2 Normal pH with decreased Pao2, and decreased Paco2

B

A postoperative client is admitted to the intensive care unit (ICU) with hypovolemic shock. Which nursing action does the nurse delegate to an experienced unlicensed assistive personnel (UAP)? Obtain vital signs every 15 minutes. Measure hourly urine output. Check oxygen saturation Assess level of alertness.

B

A postoperative hospitalized patient has a decrease in mean arterial pressure (MAP) of greater than 20 mm Hg from baseline value; elevated, thready pulse; decreased blood pressure; shallow respirations of 26/min; pale skin; moderate acidosis; and moderate hyperkalemia. The nurse recognizes that this patient is in what phase of shock? Compensatory/nonprogressive Progressive Refractory Multiple organ dysfunction

B

A young trauma patient is at risk for hypovolemic shock related to occult hemorrhage. What baseline indicator allows the nurse to recognize the early signs of shock? Urine output Pulse rate Fluid intake Skin color

B

How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? PaCO2 58 mm Hg Lactate 81 mg/dL (9.0 mmol/L) Partial thromboplastin time 64 seconds Potassium 2.8 mEq/L (2.8 mmol/L)

B

How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? Urine output 20 to 30 mL/hr for the last 4 hours Mean arterial pressure (MAP) 70 mm Hg Albumin 3.5 g/dL (5.0 mmol/L) Hemoglobin 7.6 g/dL (76 mmol/L)

B

The clinical manifestations in the first phase of sepsis-induced distributive shock result from the body's reaction to which factor? Leukocytes Infectious microorganisms Hemorrhage Hypovolemia

B

The nurse is performing a psychosocial assessment on a patient who is at risk for shock. Which statement made by the patient is of greatest concern to the nurse? "Do you have any idea when I might go home? No one is feeding my cat." "Something feels wrong, but I'm not sure what is causing me to feel this way." "I live alone in my house and my family lives in a different state" "I would usually go golfing with my friends today. I hope they're not worried about me"

B

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? Administer the antibiotic immediately. Ensure that blood cultures were drawn. Obtain signature for informed consent. Take the client's vital signs.

B

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? Localized erythema and edema Low-grade fever and mild hypotension Low oxygen saturation rate and decreased cognition Reduced urinary output and increased respiratory rate

B

Which laboratory result is seen in late sepsis? Decreased serum lactate Decreased segmented neutrophil count Increased numbers of monocytes Increased platelet count

B

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? Client receiving a blood transfusion Client with severe ascites Client with myocardial infarction Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

B

A patient at risk for shock has had some small subtle changes in behavior within the past hour. How does the nurse evaluate the patient's mental status throughout the night? Assess the patient while he or she is awake and then allow him or her to sleep until morning. Ask the patient and family to describe the patient's normal sleep and behavior patterns Periodically attempt to awaken the patient and document how easily he or she is aroused. Allow the patient to sleep but assess respiratory effort and skin temperature.

C

A patient comes to the emergency department (ED) with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? Whole blood 0.5% dextrose in water 0.9% sodium chloride Plasma protein fractions

C

Which hormones are released in response to decreased mean arterial pressure (MAP)? Select all that apply. Insulin Renin Antidiuretic hormone (ADH) Epinephrine Aldosterone Serotonin

BCDE

Which patients are at risk for shock related to fluid shifts? Select all that apply. Hypoglycemic patient Severely malnourished patient Patient with ascites Patient with kidney disease Patient with minor burns Patient with a large wound

BCDF

A patient is being discharged from the same-day surgery unit to home. Which early indicators of shock will the nurse teach the patient and family member to watch for and to seek medical attention immediately if they occur? Select all that apply, Decreased thirst Decreased urine output Increased blood pressure Lightheadedness Sense of apprehension Cyanosis

BDE

Which are specific causes or risk factors for cardiogenic shock? Select all that apply. Anesthesia Myocardial infarction Cardiac tamponade Ventricular dysrhythmias Constrictive pericarditis Cardiomyopathy

BDF

A patient is brought to the emergency department (ED) with a gunshot wound. What are the early signs of hypovolemic shock the nurse should monitor? Select all that apply. Elevated serum potassium level Increase in heart rate Decrease in oxygen saturation Marked decrease in blood pressure Increase in respiratory rate Decreased MAP of 10-15 mm Hg

BEF

A patient at risk for hypovolemic shock has a central venous pressure (CVP) catheter in place. Which finding is a priority concern for the nurse? Heart rate is decreased from 120 to 110 per minute. Central venous pressure is increased from 1 to 6 mm Hg. Central venous pressure is decreased from 6 to 1 mm Hg. Heart rate is increased from 100 to 110 per minute.

C

A patient has cardiac dysrhythmias and pulmonary problems as a result of receiving the first dose of a new IV antibiotic. The nurse recognizes that this represents what type of shock? Hypovolemic Cardiogenic Anaphylactic Septic

C

A patient in hypovolemic shock is receiving sodium nitroprusside to enhance myocardial perfusion. What is an important nursing assessment when administering this drug? Assess the patient for headache because it is an early symptom of drug excess. Assess blood pressure at least every 15 minutes because hypertension is a symptom of overdose. Assess blood pressure at least every 15 minutes because systemic vasodilation can cause hypotension. Assess the patient every 30 minutes for extravasation because nitroprusside can cause severe vasoconstriction and tissue ischemia.

C

A patient receives dopamine 20 mcg/kg/min IV for the treatment of shock. What does the nurse assess while administering this drug? Decreased urine output and decreased blood pressure Increased respiratory rate and increased urine output Chest pain and hypertension Bradycardia and headache

C

A patient with blunt trauma to the abdomen has been NPO for several hours in preparation for a procedure and now reports thirst. What is the nurse's priority action? Get the patient a few ice chips or a moistened swab. Obtain an order for a stat hematocrit and hemoglobin. Take the patient's vital signs and compare them to baseline. Obtain an order to increase the IV rate.

C

The ICU nurse is caring for a patient with septic shock. Which IV infusion order for this patient does the nurse question? Antibiotics Insulin 10% dextrose in water Synthetic activated C protein

C

The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider? Admission to rehabilitation hospital for ambulatory retraining Collaboration with home care agency for return to home Discussion with family and provider regarding palliative care Enrollment in a cardiac transplantation program

C

The nurse is caring for a patient at risk for sepsis. Why does the nurse closely monitor the patient for early signs of shock? The patient is unable to self-identify or report these early signs. Distributive shock usually begins as a bacterial or fungal infection. Prevention of septic shock is easier to achieve in the early phase. There is widespread vasodilation and pooling of blood in some tissues.

C

The nurse is caring for a patient at risk for septic shock from a wound infection. To prevent systemic inflammatory response syndrome, the nurse's priority is to monitor which factor? Patient's pulse rate and quality Patient's electrolyte imbalance Localized infected area Patient's intake and output

C

The nurse is caring for a patient in septic shock with a serum glucose level of 280 mg/dL. What is the nurse's best interpretation of this finding? The patient is developing type 2 diabetes. The patient is developing type 1 diabetes. This finding is associated with a poor outcome. This finding is unexpected in septic shock.

C

The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hyperdynamic state. Several hours later, the patient has a rapid respiratory rate, decreased urine output, and altered level of consciousness. How does the nurse interpret this change? A positive response and a signal of recovery Temporary situation that is likely to normalize Worsening of the condition rather than improvement Expected response to standard therapies

C

The nurse is caring for an older adult patient at risk for shock. What is an early sign of shock in this patient? Cool, clammy skin Decreased urinary output Restlessness Hypotension

C

The nurse is reviewing the laboratory results of a patient with a systemic infection. What is the significance of a "left shift" in the differential leukocyte count? Expected finding because the patient has a serious infection Indication that the infection is progressing toward resolution Indication that the infection is outpacing the white cell production Important to watch for trends but otherwise not urgently significant

C

The patient at risk for hypovolemic shock tells the nurse that he is very thirsty. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) first? Give the patient a cup of ice water. Assist the patient to the bathroom. Check the patient's vital signs. Ask the patient if he would like some juice.

C

The unlicensed assistive personnel (UAP) reports repeatedly and unsuccessfully trying to take a patient's blood pressure with the electronic and manual devices. The nurse notes that the patient's apical pulse is elevated and the patient is at risk for hypovolemic shock. What is the best method for the nurse to determine the systolic blood pressure? Apply the electronic device to a lower extremity. Instruct the UAP to immediately get the Doppler. Apply the manual cuff and palpate for the systolic. Tell the UAP to try the electronic device on the other arm

C

What typical sign/symptom indicates the early stage of septic shock? Pallor and cool skin Blood pressure 84/50 mm Hg Tachypnea and tachycardia Respiratory acidosis

C

Which condition results in blood vessels that are normally partially constricted? Hypoxia Vasodilation Sympathetic tone Decreased mean arterial pressure

C

Which patient is at risk for obstructive shock? Patient with a history of angina Patient with chronic atrial fibrillation Patient with a pulmonary embolus Patient with a history of heart failure

C

Which problem places a client at highest risk for sepsis? Pernicious anemia Pericarditis Post kidney transplant Client owns an iguana

C

With which client should the nurse remain alert for possible sepsis and septic shock? 41 year old man who sustained closed depression fracture of the face when hit with a baseball 53 year old woman who had an open abdominal hysterectomy 3 days agp to remove several large fibroid tumors 67 year old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago 72 year old man with severe allergies who is undergoing radiation therapy for early stage prostate cancer

C

The nurse is evaluating the care and treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment? Blood pH of 7.28 Arterial PO2 of 65 mm Hg Distended neck veins Increased urinary output

D

The nurse is performing a morning shift assessment on several patients. For which patient is the nurse immediately concerned about decreased tissue perfusion if the capillary refill time was delayed? Patient with diabetes mellitus Anemic patient Patient with peripheral vascular disease Patient with severe dehydration

D

The student nurse is assessing a patient's mental status because of the patient's risk for decreased tissue perfusion. The supervising nurse intervenes when the student nurse asks the patient which question? "What is today's date?" "Who is the president of this country?" "Where are we right now?" "Is your name Mr. John Smith?"

D

When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? Obtain IV access and hang prescribed fluid infusions. Apply the automatic blood pressure cuff. Assess level of consciousness and pupil reaction to light. Check the airway and respiratory status

D

Which IV therapy results in the greatest increase in oxygen-carrying capacity for a patient with hypovolemic shock? Lactated Ringer's solution Hetastarch Fresh frozen plasma (FFP) Packed red cells

D

Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? Oxygen saturation remains unchanged. Core body temperature has increased to 99° F (37.2° C). The client correctly states the month and year. Serum lactate and serum potassium levels are declining.

D

Which nurse would be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? The LPN/LVN who has 20 years of experience The new RN who recently finished orienting and is working independently with moderately complex clients The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago The RN with 2 years of experience in intensive care unit (ICU)

D

A 70-year-old man is admitted to the hospital With an infected finger of several days duration. He is lethargic and confused and has a temperature of 101.3°F (38,5°C). Other assessment findings include blood pressure of 94/50 mmHg, pulse 105 beats/ min, respirations 40/ min, and shallow breathing. These assessment findings indicate which type of shock? Hypovolemic Cardiogenic Anaphylactic Septic

D

A patient has a localized infection. What assessment findings are considered evidence of a beneficial inflammatory response? Decreased urine output that normalizes after fluid bolus Pulse rate of 120 beats/min related to increased metabolic activity Decreased oxygen saturation that responds to supplemental O2 Redness and edema that subside in several days

D

A patient is at risk for sepsis. Which assessment finding is most indicative of the hyperdynamic activity that occurs in septic shock? Crackles in lung bases Weak, rapid peripheral pulses Cool, clammy, cyanotic skin Increased pulse rate with warm, pink skin

D

A patient with head trauma was treated for a cerebral hematoma. After surgery, this patient is at risk for what type of shock? Obstructive Cardiogenic Chemical-induced distributive Neural induced distributive

D

The ICU nurse observes petechiae, ecchymoses, and blood oozing from gums and other mucous membranes of a patient with septic shock. How does the nurse interpret this finding? Pulmonary emboli (PE) Acute respiratory distress syndrome(ARDS) Systemic inflammatory response syndrome (SIRS) Disseminated intravascular coagulation(DIC)

D

The nurse is caring for a patient at risk for hypovolemic shock. What is the first sign of hypovolemic shock the nurse should monitor? Elevated body temperature Decreasing urine output Vasodilation Increasing heart rate

D

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? Hypotension Bradypnea Heart blocks Tachycardia

D

Which problem places a person at highest risk for septic shock? Kidney failure Cirrhosis Lung cancer 40% burn injury

D