Med surg 2. Chapter 14

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?

The patient has developed a stress ulcer that is bleeding.

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.)

Urinary output Mental status Vital signs

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?

Use strict hand hygiene techniques.

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

5% albumin

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.

60 mm Hg

Which of the following would be a pulse pressure indicative of shock?

90/70

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.)

A heart rate >100 bpm Crackles Lethargy and mental confusion

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:

A myocardial infarction.

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

A rapid, bounding pulse

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?

WBC: 42,000/mm3

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first?

Administer an epinephrine injection.

Which type of shock occurs from an antigen-antibody response?

Anaphylactic

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

Aortic insufficiency

You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

Arterial blood gas (ABG) findings

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the patient's prognosis? (Select all that apply.)

Assess the patient who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:

Blood pressure.

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

Brain

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient?

Disseminated intravascular coagulation (DIC)

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to

Encourage the family to touch and talk to the client.

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply.

Famotidine (Pepcid) Ranitidine (Zantac) Lansoprazole (Prevacid)

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices?

Hanging tape on the bedside table when changing a wet-to-dry sterile dressing

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?

Head injury

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?

In the compensation stage, catecholamines are released.

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?

Intubation and mechanical ventilation

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction:

Jugular venous distention

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess

Lung sounds

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Maintain activity restriction to bedrest.

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position?

Modified Trendelenburg

Which positioning strategy should be used for the patient diagnosed with hypovolemic shock?

Modified Trendelenburg

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption?

Morphine

A 17-year-old-male client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?

Neurogenic shock

The nurse is evaluating a client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?

Organ damage

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

Oxygen at 2 L/min by nasal cannula

The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

Place the client in a modified Trendelenburg position.

You are assessing a 6-year-old little girl in the Emergency Department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?

She is having an allergic reaction and going into anaphylactic shock.

You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family?

The client is not responding to medical interventions.

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following?

The difference between the systolic and diastolic pressure

A nurse knows that the major clinical use of dobutamine (Dobutrex) is to:

increase cardiac output.

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

ondansetron (Zofran)

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct?

"The client is in shock because the blood volume has decreased in the system."

A patient is in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse?

"The healthcare team needs room to do procedures to help your family member, so it would be best if you stayed in the waiting area."

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?

Distributive