RN 402 ATI Shock Practice Questions

A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take?

Administer Antibiotic therapy

A septic patient with hypotension is being treated with dopamine hydrochloride. The nurse asks a colleage to double-check the dosage that the client is receiving. There are 400 mg of dopamine hydrochloride in 250 ml D5W, the infusion pump is running at 23 ml/hr, and the client weighs 79.5 kg. How many micrograms per kilogram per minute (mcg/kg/min) is the client receiving? Do not round off your answer

7.71 mkg/kg/min

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A. Confusion B. lethargy C. unconsciousness d. Petechiae

A. Confusion Rationale: Confusion characterizes the compensatory stage of shock, as do decreased urinary output, cold and clammy skin, and respiratory alkalosis

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings? A. Fatigue B. Respiratory depression C. Bradycardia D. Muscle cramps

A. Fatigue Rationale: Fatigue is an expected finding with a client who has anemia due to surgical blood loss. This is because of the decreased ability of the body to carry oxygen to vital tissues and organs.

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? A. Give PRN furosemide (Lasix) 40 mg IV. B. Increase normal saline infusion to 250 mL/hr. C. Administer hydrocortisone (Solu-Cortef) 100 mg IV. D. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg

A. Give PRN furosemide (Lasix) 40 mg IV. Rationale: ANS: 1Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.

A nurse on a critical care unit is caring for a client who has shallow and rapid respirations, paradoxical pulse, CVP 4 cm H2O, BP 90/50 mm Hg, skin cold and pale, and urinary output 55 mL over the last 2 hr. From these findings, the nurse concludes that he may be developing which of the following? A. Hypovolemic shock B. Cardiac tamponade C. Sepsis D. Atelectasis

A. Hypovolemic shock Rationale: The client's signs and symptoms are all indicative of hypovolemic shock. The nurse should conclude that the client may be developing this outcome.

A nurse is assessing a client who has an 8 score using the Glasgow Coma Scale to evaluate levels of consciousness. Which of the following nursing statements most accurately describes the score? A. Indicates the need for total nursing care B. Reflects an alert client C. Indicates a client in a deep coma D. Indicates stable neurological status

A. Indicates the need for total nursing care Rationale: The nurse understands a Glasgow Coma score of 8 indicates the client is in a coma and requires total nursing care.

A nurse is caring for client whose throat culture is positive for group A streptococcus 24 hr after the rapid strep test (RST) was negative. Which of the following is the priority nursing action?

A. Notify the client to return to the clinic for initiation of antibiotic therapy

A client is admitted to the emergency room with a respiratory rate of seven per min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm HG Saturation 80% Bicarbonate 28 mEq/L

A. Respiratory acidosis

Assuming that vascular volume is adequate, which medication would have the strongest effect on raising the blood pressure in a hypotensive patient? A. norepinephrine (Levophed). B. dobutamine (Dobutrex). C. epinephrine (Adrenalin). D. esmolol (Brevibloc).

A. norepinephrine (Levophed).

A nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. Which of the following actions should the nurse anticipate performing?

Assist with the insertion of pulmonary artery catheter

Following surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? A. Administer IV diuretic medications. B. Increase the IV fluid infusion per protocol. C. Document the CVP and continue to monitor. D. Elevate the head of the patient's bed to 45 degrees

B. Increase the IV fluid infusion per protocol. Rationale: ANS: 2A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP.

A client with a BMI of 60.2 kg/mm is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending MODS. What should the nurse prepare to implement first? A. Platelet transfusion B. Mechanical ventilation C. Loop diuretic therapy D. Cyanocobalamin administration

B. Mechanical ventilation

Six hours after surgery of a ruptured appendix, a client has a WBC of 17, abdominal tenderness, and abdominal rigidity. The nurse should recognize that the client is exhibiting symptoms of which condition? A. Regional enteritis. B. Peritonitis. C. Colitis. D. Gastritis

B. Peritonitis.

When initiating a dopamine IV infusion for hypotensive client, which intervention should the nurse include in the client's plan of care? A. Assess bilateral breath sounds. B. Perform neuro assessment every 12 hours. C. Monitor urine output every hour. D. Observe pulmonary capillary wedge pressure

C. Monitor urine output every hour.

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Hypotension B. Decreased urine output C. Narrowing pulse pressure D. Decreased level of consciousness

C. Narrowing pulse pressure Rationale: Narrowing pulse pressure is the earliest indicator of shock.

When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment? A. Central venous pressure (CVP) B. Systemic vascular resistance (SVR) C. Pulmonary vascular resistance (PVR) D. Pulmonary artery wedge pressure (PAWP)

C. Pulmonary vascular resistance (PVR) Rationale: ANS: 3PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored but

On admission to the intensive care unit for sepsis due to ruptured appendix, a female client's temperature is 39.8 degree celcius and her blood pressure is 68/42 mm Hg. Other hemodynamic findings include cardiac output of 10.7 L/min, SVR 4802 dynes/sec/cm5, and WBC 28,000. Which classification of medications is likely to stabilize the client? A. ACE inhibitors. B. Negative inotropes. C. Vasoconstrictors. D. Diuretics

C. Vasoconstrictors.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased heart rate Rationale: The heart rate of a client with hypovolemia will be increased. B. Dyspnea Rationale: Dyspnea is characteristic of respiratory conditions, but is not usually associated with hypovolemia. C. Increased blood pressure Rationale: The client's blood pressure will decrease due to decreased blood volume. D. Thready pulse

D. Thready pulse Rationale: A decreased volume of circulating blood and less pressure within the vessels results in weak thready peripheral pulses and flattened neck veins

A nurse in the emergency department is caring for a client who had an allergic reaction related to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first?

Epinephrine IV

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a.Normal body temperature b.Balanced intake and output c.Adequate pain management d.Urine output of 0.5 mL/kg/hr

d.Urine output of 0.5 mL/kg/hr

A nurse is caring for a client who has a prescription for an afterload‐reducing medication.The nurse should identify that this medication is administered for which of the following types of shock?

Cardiogenic

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect?

Seizure activity Respiratory rate 42/min Weak, thready pulse

A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a.Human albumin infusion b.Hypotonic saline solution c.Lactated Ringer's bolus d.Packed red blood cells

c.Lactated Ringer's bolus

The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? a."The action of the machine will improve blood supply to the damaged heart." b."The machine will beat for the damaged heart with every beat until it heals." c."The machine will help cleanse the blood of impurities that might damage the heart." d."The machine will remain in place until the patient is ready for a heart transplant."

a."The action of the machine will improve blood supply to the damaged heart."

The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a.The patient is developing neurogenic shock. b.The patient is experiencing an allergic reaction. c.The patient most likely has an elevated temperature. d.The vital signs are normal for this patient.

a.The patient is developing neurogenic shock.

A nurse is caring for an adult client who is in the compensatory stage of shock. Which of the following is an expected finding? a. mottled skin b. blood pressure 115/68 mmHg c. heart rate 160/min d. metabolic acidosis

b. blood pressure 115/68 mmHg

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? a.Diphenhydramine (Benadryl) 50 mg intravenously b.Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c.Methylprednisolone (Solu-Medrol) 125 mg intravenously d.Ranitidine (Zantac) 50 mg intravenously

b.Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? a.Blood transfusion with packed red blood cells is required. b.Hemoglobin and hematocrit results indicate hemodilution. c.Fluid resuscitation has resulted in fluid volume overload. d.Fluid resuscitation has resulted in third spacing of fluid.

b.Hemoglobin and hematocrit results indicate hemodilution.

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a.Creatinine 1.0 mg/dL b.Lactate 6 mmol/L c.Potassium 3.8 mEq/L d.Sodium 140 mEq/L

b.Lactate 6 mmol/L

A nurses is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has septic shock. Which of the following nursing statements indicates an understanding of the condition? A. "DIC is controllable with lifelong heparin usage." b. "DIC is characterized by an elevated platelet count" c. C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving vitamin K deficiency."

c. C. "DIC is caused by abnormal coagulation involving fibrinogen."

A nurse in the emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following is the priority intervention?

c. auscultate for wheezing

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following should the nurse expect in the findings?

c. excessive thrombosis and bleeding

18.A nurse is caring for a client who has hypovolemic shock. Which of the following is an expected finding? a. hypertension b. purpura c. oliguria d. bradypnea

c. oliguria

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? a.Administration of atropine sulfate (Atropine) b.Application of 100% oxygen via facemask c.Application of slow rewarming measures d.Infusion of IV phenylephrine (Neo-Synephrine)

c.Application of slow rewarming measures

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex). The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? a.Obtain a stat serum potassium level. b.Order a stat 12-lead electrocardiogram. c.Reduce the rate of dobutamine (Dobutrex). d.Assess the patient's hourly urine output.

c.Reduce the rate of dobutamine (Dobutrex)

A triage nurse in an emergency department is caring for a client who has a gunshot wound to the right side of her chest. The nurse notes a thick dressing on the chest and a sucking noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take initially? a. raise the foot of the bed to a 90 degree angle b. remove the dressing to inspect the wound c. prepare to insert a central line d. administer O2 via nasal cannula

d. administer O2 via nasal cannula

A client experiences anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? a. dobutamine b. corticosteriods c. furosemide d. epinephrine

d. epinephrine rationale: Epinephrine does reverse the most severe manifestations of anaphylactic shock; therefore, should be the treatment of choice.

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? a. decrease in the resp. rate from 20 to 16 b. decrease in urinary output from 50 to 30 mL per hour c. increase the temperature from 37.5 to 38.6 d. increase in heart rate from 88 to 110

d. increase in heart rate from 88 to 110

A nurse is caring for a client who has hypovolemic shock. Which of the following blood products does the nurse anticipate administering to this client? A. Cryoprecipitates B. Platelets C. Fresh frozen plasma (FFP) d. Pack red blood cells

d. pack red blood cells

A nurse is caring for four hospitalized clients. Which of the following clients is at greatest risk for fluid volume deficit?

d. the client who has just been admitted, has gastroenteritis and is febrile

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a.The assessed values are within normal limits. b.The patient is at risk for developing cardiogenic shock. c.The patient is at risk for developing fluid volume overload. d.The patient is at risk for developing hypovolemic shock.

d.The patient is at risk for developing hypovolemic shock.

The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a.Blood pressure b.Heart rate c.Level of consciousness d.Pupil response e.Respirations f.Urine output

a. blood pressure c. LOC f

After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which active physician order first? a.Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg. b.Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. c.Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. d.Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101° F.

a.Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg.

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a.Assess the blood pressure by Doppler. b.Estimate the systolic pressure as 60 mm Hg. c.Obtain an electronic blood pressure monitor. d.Record the blood pressure as "not assessable."

a.Assess the blood pressure by Doppler.

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a.Blood cultures b.Chest x-ray c.Foley insertion d.Serum electrolytes

a.Blood cultures

******The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a.Cardiac index (CI) of 2.5 L/min/m2 b.Pulmonary artery diastolic pressure of 26 mm Hg c.Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d.Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5

a.Cardiac index (CI) of 2.5 L/min/m2

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority?a.Central nervous system b.Gastrointestinal system c.Renal system d.Respiratory system

a.Central nervous system

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention?a.Dobutamine (Dobutrex) b.Furosemide (Lasix) c.Phenylephrine (Neo-Synephrine) d.Sodium nitroprusside (Nipride)

a.Dobutamine (Dobutrex)

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central line-associated bloodstream infection (CLABSI)? a.Documentation of insertion date b.Elevation of the head of the bed c.Assessment for weaning readiness d.Appropriate sedation management

a.Documentation of insertion date

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a.High pulmonary artery diastolic pressure and low cardiac output b.Low pulmonary artery occlusive pressure and low cardiac output c.Low systemic vascular resistance and high cardiac output d.Normal cardiac output and low systemic vascular resistance

a.High pulmonary artery diastolic pressure and low cardiac output

The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? a.Insertion of an 18-gauge peripheral intravenous line b.Application of cushioned heel protectors c.Implementation of fall precautions d.Implementation of universal precautions

a.Insertion of an 18-gauge peripheral intravenous line

The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a.Patient response to therapy is appropriate. b.Additional interventions are indicated. c.More time is needed to assess response. d.Values are normal for the patient condition.

b.Additional interventions are indicated.

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) a.Administer acetaminophen (Tylenol). b.Document the patient's response. c.Increase the rate of transfusion. d.Notify the blood bank. e.Notify the physician. f.Stop the transfusion.

b.Document the patient's response. d.Notify the blood bank. e.Notify the physician. f.Stop the transfusion.

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm-5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a.Furosemide (Lasix) 20 mg intravenous (IV) every 4 hours as needed for CVP > 20 mm Hg b.Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain c.Dobutamine (Dobutrex) infusion at a rate of 2-20 mcg/kg/min as needed for CI < 2 L/min/m2 d.Dopamine (Intropin) infusion at a rate of 5-10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

b.Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain

The nurse is administering intravenous norepinephrine (Levophed) at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse? a.Blood pressure 100/60 mm Hg b.Swelling at the IV site c.Heart rate of 110 beats/min d.Central venous pressure (CVP) of 8 mm Hg

b.Swelling at the IV site

The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? a.Administer acetaminophen (Tylenol) 650-mg suppository prn every 6 hours for pain. b.Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic. c.Complete neurological assessment every 4 hours for the next 24 hours. d.Administer furosemide (Lasix) 20 mg IV every 4 hours for a CVP > 20 mm Hg.

b.Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic.

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a.A patient admitted with abdominal pain and an elevated white blood cell count b.A patient with a temperature of 102° F and a general dermal rash c.A patient with a 2-day history of nausea, vomiting, and diarrhea d.A patient with slight rectal bleeding from inflamed hemorrhoids

c.A patient with a 2-day history of nausea, vomiting, and diarrhea

The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? a.Administer pain medication. b.Turn patient every 2 hours. c.Assess core body temperature. d.Apply bilateral heel protectors.

c.Assess core body temperature.

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a.Frequent turning b.Monitoring intake and output c.Enteral feedings d.Pain management

c.Enteral feedings

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? a.Administer blood transfusion over at least 4 hours. b.Notify the physician of the elevated temperature. c.Titrate rate of blood administration to patient response. d.Notify the physician of the patient's heart rate.

c.Titrate rate of blood administration to patient response.

******During the initial stages of shock, what are the physiological effects of decreased cardiac output? a.Arterial vasodilation b.High urine output c.Increased parasympathetic stimulation d.Increased sympathetic stimulation

d.Increased sympathetic stimulation

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? a.Acetaminophen suppository b.Blood cultures from two sites c.IV antibiotic administration d.Isotonic fluid challenge

d.Isotonic fluid challenge

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a.High pulmonary artery occlusive pressure and high cardiac output b.High systemic vascular resistance and low cardiac output c.Low pulmonary artery occlusive pressure and low cardiac output d.Low systemic vascular resistance and high cardiac output

d.Low systemic vascular resistance and high cardiac output

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a.Breath sounds and capillary refill b.Blood pressure and oral temperature c.Oral temperature and capillary refill d.Right atrial pressure and urine output

d.Right atrial pressure and urine output

The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a.pH 7.40, CO2 40, HCO3 24 b.pH 7.45, CO2 45, HCO3 26 c.pH 7.35, CO2 40, HCO3 22 d.pH 7.30, CO2 45, HCO3 18

d.pH 7.30, CO2 45, HCO3 18