NUR240 Ch. 34

The nurse is evaluating the plan of care for a patient with hypovolemic shock to determine whether circulation has improved. Which cue would lead the nurse to document that the goal is met? Select all that apply. One, some, or all responses may be correct.

24-hour urine output 1200 mL Palpable pedal pulses bilaterally Mean arterial pressure 73 mm Hg Rationale: The nurse would document the goal has been met when the patient has a 24-hour urine output of 1200 mL as this indicates good renal perfusion and circulation. Palpable pedal pulses indicate good peripheral circulation. A mean arterial pressure of 73 mm Hg also indicates a normal blood pressure, which indicates the goal is met. An apical heart rate of 82 beats/min is normal but does not reflect that adequate circulation is being maintained. IV fluids infusing at 100 mL/hr is an intervention to maintain circulatory volume, not evidence the goal is met.

Which patient is at the highest risk for developing septic shock?

A 65-year-old with prostate cancer receiving chemotherapy Rationale: The 65-year-old with prostate cancer receiving chemotherapy is at the highest risk for developing septic shock. The 45-year-old with pancreatitis is at a lower risk for a decreased immune system than the older adult with cancer and chemotherapy. The 20-year-old with testicular cancer and an orchiectomy (removal of the testicle) is at a lower risk than the older adult with cancer. The 70-year-old is having an elective surgery; this does not indicate a decrease in the immune system.

Which factor would the nurse assess for complications related to an overdose of sodium nitroprusside to treat hypovolemic shock?

Blood pressure Rationale: An overdose of sodium nitroprusside causes systemic vasodilation, which leads to hypotension. Therefore the blood pressure should be assessed and brought back to normal as well as monitored every 15 minutes. Headache is a result of dopamine overdose and is not associated with sodium nitroprusside. Chest pain is monitored to check if there is an increase in myocardial oxygen consumption. Overdoses of drugs like dopamine and dobutamine, not sodium nitroprusside, increase myocardial oxygen consumption. Urine output assessment is not associated with sodium nitroprusside. It is monitored while administering dopamine because dopamine overdose reduces urine output.

Which assessment factor is used to verify the effectiveness of norepinephrine to treat hypovolemic shock?

Blood pressure Rationale: Norepinephrine is a vasoconstrictor drug used in hypovolemic shock to increase perfusion and oxygenation. These drugs constrict the blood vessels and increase venous return. Urine production will not increase until blood pressure rises and perfuses the kidneys. Norepinephrine does not have any effect on a patient's level of consciousness or blood glucose levels.

Which problem places a patient at the highest risk for septic shock?

Burns on 40% of the body Rationale: The skin forms the first barrier to prevent entry of organisms into the body; a patient with burns on 40% of the body is at very high risk for sepsis and death. Although a patient with kidney failure has an increased risk for infection, the skin is intact, unlike a patient with a burn injury. Although the liver acts as a filter for pathogens, s patient with cirrhosis has intact skin, unlike a patient with a burn injury. A patient with lung cancer may be at risk for increased secretions and infection, but the risk is not as high as for a patient with open skin.

Which clinical manifestation may be associated with septic shock?

Cool skin Rationale: In septic shock, the skin becomes cold when the cardiac output decreases below the normal level. The urine output of 30 mL/hr indicates normal conditions. A lactic acid level of 5 mg/dL is normal because the normal level of lactic acid lies between 3 and 7 mg/dL. A mean arterial pressure of 90 mm Hg indicates normal functioning of the body organs.

Which abnormality would the nurse expect to see when reviewing the arterial blood gas results for a patient with hypovolemic shock?

Elevated lactic acid Rationale: The nurse would expect to find an elevated lactic acid level in a patient with hypovolemic shock. Other findings would include a decreased pH and Pao2 and an increased Paco2.

Which physiologic change is related to septic shock?

Elevated white blood cell (WBC) count Rationale: Septic shock is always due to an underlying infection. An elevated WBC count is associated with septic shock. There is a progressive organ dysfunction resulting in low blood pressure and decreased urinary output. The respiratory rate is increased to compensate for hypoxia in the tissues.

In which position will the nurse place a patient whose heart rate suddenly increases to 122 beats/min and blood pressure drops to 84/48 mm Hg to improve the patient's blood pressure and organ perfusion?

Feet elevated, head of bed flat Rationale: Maintaining the patient flat with the feet elevated improves venous return and perfusion to the brain. Sims position refers to lying on the left side with the top leg flexed, typically used for enemas and GI procedures. The lithotomy position is used for gynecologic examination and procedures. The head of bed elevated at 30 degrees describes a semi-Fowler position used to prevent aspiration.

Which factor will the nurse assess for in a patient at risk for sepsis who is scheduled for discharge the next day? Select all that apply. One, some, or all responses may be correct.

General cleanliness Availability and use of refrigerator Type of soap used for handwashing Presence of pets, especially cats Type and amount of food consumed at each meal Rationale: Protecting frail patients from infection and sepsis at home is an important nursing function. It is important for the nurse to assess the patient's home environment, including general cleanliness; kitchen and bathroom facilities including refrigeration, availability and type of soap for handwashing; and the presence of pets, especially cats. The nurse will teach about the importance of self-care strategies, such as good hygiene, handwashing, balanced diet (including type and amount of food consumed at each meal), rest and exercise, skin care, and mouth care.

Which action would the nurse take to decrease a patient's risk for shock? Select all that apply. One, some, or all responses may be correct. Correct1

Give antibiotics. Administer oxygen. Initiate inotropic drugs. Monitor blood pressure. Obtain serum lactate level. Rationale: The nurse should administer antibiotics to fight infection. Oxygen should be given to improve gas exchange. Inotropic drugs increase the contractility of the heart. Blood pressure should be monitored as a decrease is an early sign of septic shock. An increasing serum lactate level would indicate presence of sepsis.

Which condition is the nurse concerned about in a 35-year-old patient whose chart contains the provided laboratory results?

Hemorrhage Rationale: According to the patient's blood report, the patient's total body fluid has decreased. The patient's Pao2 is low, the carbon dioxide level is elevated, and hematocrit and hemoglobin levels are reduced, indicating hypovolemic shock caused by hemorrhage. Increased potassium levels are an indication of acidosis; in this case, the patient's potassium level is normal. Elevated rather than decreased hematocrit and hemoglobin levels are indications of hypovolemic shock caused by dehydration. The patient's Pao2, hematocrit value, and hemoglobin levels have decreased, which reflects loss of body fluid, not an increase in fluid. In cases of decreased cardiac function, the total body fluid is not affected.

Which condition may be associated with a hematocrit level of 29%?

Hemorrhage Rationale: n hemorrhage, the hematocrit value decreases from the normal adult level of 42% to 52% for men and 37% to 47% for women. Edema results from fluid shift, which causes hematocrit levels to increase. Dehydration also results in an elevated hematocrit value.

Which clinical manifestation may be evident in the initial stage of hypovolemic shock?

Increase in heart and respiratory rate Rationale: The initial stage of hypovolemic shock can be detected only by an increase in heart and respiratory rates. Reduction in urine output is a manifestation of the compensatory stage. Antidiuretic hormone increases water reabsorption in the kidneys, which results in decreased urine output. In the initial stage of hypovolemia, the compensatory mechanisms are efficient in maintaining cardiac output, so there is no overall decrease in cardiac output. A 2% to 5% decrease in oxygen saturation indicates the compensatory stage of hypovolemia.

Which issue would the nurse anticipate finding in a patient with septic shock who has disseminated intravascular coagulation (DIC)?

Low fibrinogen levels Rationale: Late in septic shock, hematocrit and hemoglobin levels, fibrinogen levels, and platelet count are low from DIC. A reduction in red blood cells, hemoglobin, and hematocrit, rather than an increase (polycythemia), occur in DIC. Thrombocytopenia (a reduction of platelets) rather than thrombocytosis (an increased number of platelets) occurs as these components are incorporated into the multiple small clots that develop in DIC. The serum lactate level is above normal, and the serum bicarbonate levels are lower than normal.

Which clinical symptoms in a postoperative patient indicate early sepsis with an excellent recovery rate if treated?

Low-grade fever and mild hypotension Rationale: Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and an increased respiratory rate indicate severe sepsis.

Which assessment finding is a cardiovascular manifestation of hypovolemic shock? Select all that apply. One, some, or all responses may be correct.

Narrow pulse pressure Postural hypotension Decreased cardiac output Rationale: In hypovolemic shock, total body fluid is reduced; therefore the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also, causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.

Which intervention would the nurse implement first for a patient who has been newly admitted for suspected septic shock?

Obtain blood cultures. Rationale: Obtaining blood cultures should be the first intervention when septic shock is suspected. This should be done before administering antibiotics, so the physician can determine the best antibiotic to use to treat the patient. Inserting an indwelling catheter and assessing bowel sounds can occur after blood cultures have been obtained if necessary.

Which intervention would the nurse perform first for a patient who presents with sepsis and whose laboratory report shows a serum lactate level of 40 mg/dL?

Obtaining blood cultures Rationale: The Surviving Sepsis Campaign (SSC) is a national initiative that was started to standardize sepsis care and promote early recognition of patients with sepsis and septic shock. Hour-1 bundle guidelines were developed to reduce sepsis-related deaths. The lactate level should be measured first (in this case, this was already done). Then the nurse would obtain blood cultures before administering broad-spectrum antibiotics. The nurse would then begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L (72 mg/dL). A patient with septic shock is likely to be mechanically ventilated; however, this is more likely as sepsis progresses to septic shock.

A patient with which problem or condition is at highest risk for septic shock?

On prednisone therapy for rheumatoid arthritis Rationale: Patients who do not have intact immune systems are at highest risk for sepsis and septic shock, including those who have had organ transplants, with human immune deficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), kidney or liver disease, the very old, and those with invasive lines and procedures. Prednisone, taken for autoimmune diseases such as rheumatoid arthritis, suppresses the immune system and prevents further damage to the joints. Although obesity, surgery, and hospitalization for myocardial infarction pose some risk for infection and sepsis, the use of corticosteroid medications is an actual risk for the development of sepsis and septic shock.

A patient with which issue has an increased risk for hypovolemic shock?

Overdosed on bumetanide Rationale: Hypovolemic shock results from decreased circulating blood volume; bumetanide, a potent loop diuretic, decreases blood volume. Kidney failure results in increased blood volume (hypervolemia) as the failing kidney is unable to produce urine. A myocardial infarction may lead to cardiogenic shock or heart failure, with resulting fluid volume excess rather than hypovolemia. BPH obstructs the outflow of urine into the bladder as prostatic tissue enlarges; blood volume is not reduced.

Which sign or symptom occurs in the compensatory stage of shock? Select all that apply. One, some, or all responses may be correct.

Restlessness Increased respiratory rate Decreased urine output Tachycardia Rationale: Signs and symptoms of the compensatory stage of shock include changes resulting from decreased tissue perfusion. Objective changes include restlessness, increased respiratory rate, decreased urine output, and tachycardia. Cyanosis appears later, in the progressive stage of hypovolemic shock.

A patient has hypovolemic shock secondary to a stab wound. Place the nursing interventions in the appropriate order of priority.

The immediate priority in all types of shock is to ensure a patent airway. Then elevate the patient's legs. Next, obtain IV access and fluid resuscitation with normal saline or lactated Ringer's solution. If adequate tissue perfusion and blood pressure are not attained, vasopressors are then initiated.