Sepsis, MODS, Shock

The nurse is caring for a patient with papillary muscle rupture. The nurse would be most alert to the development of which type of shock? 1. Septic 2. Cardiogenic 3. Anaphylactic 4. Neurogenic

2. Cardiogenic

A critically ill patient has developed multiple organ dysfunction syndrome (MODS). What should the nursing goal for management of the patient with impending MODS center on? A) Early normalization of SvO2 and acidbase balance B) Use of intravenous drotrecogin alfa (Xigris) C) Specific organ system support D) General intensive nursing care

A) Early normalization of SvO2 and acidbase balance

The patient has developed cardiogenic shock and is decompensating. What pattern of hemodynamic alterations does the nurse expect to find? A) High preload, high afterload, low cardiac index, tachycardia B) Low preload, low afterload, high cardiac index, bradycardia C) Low preload, high afterload, high cardiac index, tachycardia D) High preload, low afterload, high cardiac index, tachycardia

A) High preload, high afterload, low cardiac index, tachycardia

The nurse is caring for a patient with hypovolemic shock who has had 6 units of packed red blood cells. Which of the following values would alert the nurse to a complication related to the administration of blood? A) Potassium level of 6.0 B) Hemoglobin of 13 C) Sodium level of 134 D) pH 7.37

A) Potassium level of 6.0

The nurse is administering an intravenous antibiotic infusion over 30 minutes for a patient with cellulitis of the left lower extremity. The patient states, I am itching all over and am having trouble swallowing. What priority interventions by the nurse are necessary for this patient? Select all that apply. A) Stop the antibiotic infusion. B) Administer subcutaneous epinephrine. C) Administer diphenhydramine (Benadryl) IV. D) Switch to amoxicillin by mouth. E) Administer Ativan for the patients anxiety.

A) Stop the antibiotic infusion. B) Administer subcutaneous epinephrine. C) Administer diphenhydramine (Benadryl) IV.

A nursing assessment of a patient with hypovolemic shock is most likely to reveal what assessment findings? Select all that apply. A) Tachycardia B) Oliguria C) Disoriented to time and place D) Diuresis E) Bradycardia F) Hypotension

A) Tachycardia B) Oliguria C) Disoriented to time and place F) Hypotension

A critically ill patient who is mechanically ventilated and has developed shock is in need of nutritional support. What route is preferred for this patient? A) Oral B) Enteral C) Parenteral D) Variable

B) Enteral

A critically ill patient has developed shock. What nursing assessment result indicates a normal compensatory mechanism? A) Reduction of respiratory depth B) Increase in systemic vascular res istance (SVR) C) Decrease in circulating catecholamines D) Increased stimulation of baroreceptors

B) Increase in systemic vascular res istance (SVR)

A critically ill patient has developed septic shock. What pattern of hemodynamic values does the nurse expect to find? A) Low preload, high afterload, low cardiac index, tachycardia B) Low preload and afterload, high cardiac index, tachycardia C) High preload and afterload, low cardiac index, tachycardia D) Normal preload, low afterload, normal cardiac index, bradycardia

B) Low preload and afterload, high cardiac index, tachycardia

The nurse is assigned to the care of a patient in the ICU who is in cardiogenic shock. What priority nursing intervention is necessary to conserve myocardial energy and decrease workload of the heart? A) Lactated Ringers at 150 mL/hr B) Morphine sulfate 4 mg IV C) Furosemide (Lasix) 80 mg IV D) Epinephrine 1:1,000, 0.3 mL IV

B) Morphine sulfate 4 mg IV

For a patient in cardiogenic shock, the physician has ordered an intravenous continuous infusion of dobutamine hydrochloride. What nursing assessment result demonstrates achievement of therapeutic goals? A) Blood pressure 120/70 mm Hg B) Urine output 30 to 40 mL/hr C) Arterial oxygen saturation 60% D) Heart rate 110 to 120 bpm

B) Urine output 30 to 40 mL/hr

In developing the discharge plan for a patient who was treated in the hospital for anaphylactic shock related to a nonsteroidal anti-inflammatory (NSAID) allergy, what would be the most important information for the nurse to include? A) Adhere to dietary restrictions. B) Follow up in one month with the physician. C) Check labels of over-the-counter medications prior to taking. D) Have blood pressure checked on a regular basis.

C) Check labels of over-the-counter medications prior to taking.

The nurse in the ICU is assigned to care for a patient with septic shock. What nursing interventions are necessary to prevent malnutrition and optimize cellular function in this patient? A) Administration of crystalloid solutions IV B) High calorie, low protein diet C) Enteral feedings D) Administration of multivitamins in the IV fluid

C) Enteral feedings

The nurse is assigned to a patient in the ICU who is on a ventilator for exacerbation of chronic obstructive pulmonary disease. What intervention by the nurse can prevent the development of multiple organ dysfunction syndrome? A) Suctioning the patient every 2 hours B) Enteral feedings C) Oral care every 2 hours D) Administration of total parenteral nutrition

C) Oral care every 2 hours

A patient is being treated for severe hypovolemic shock. Based on the primary treatment goal, what nursing intervention has the highest priority? A) Frequent measurement of vital signs B) Management of mechanical ventilation C) Rapid intravenous fluid administration D) Insertion of urinary drainage catheter

C) Rapid intravenous fluid administration

A patient is in shock and is exhibiting low blood pressure, low systemic vascular resistance (SVR), peripheral edema, pulmonary wheezing, tachycardia, and nausea and vomiting. What precipitating event does the nurse expect for this group of symptoms? A) Acute myocardial infarction B) Bacterial infectious illness C) Recent seafood meal D) Massive fluid loss

C) Recent seafood meal

A patient in shock has developed systemic inflammatory response syndrome (SIRS). What is the most likely type of shock resulting in SIRS? A) Hypovolemic B) Septic C) Cardiogenic D) Any shock

D) Any shock

The patient has been diagnosed with shock secondary to an antigenantibody reaction. What collaborative intravenous intervention has the highest priority? A) Dobutamine B) Red blood cells C) Antimicrobials D) Epinephrine

D) Epinephrine

The patient is in decompensated cardiogenic shock. What collaborative intervention best addresses the central cause of cardiogenic shock? A) Mechanical ventilation B) Hemodynamic monitoring C) Pharmacologic sedation D) Intravenous nitrate infusion

D) Intravenous nitrate infusion

What would the nurse identify as the primary purpose for the administration of intravenous (IV) crystalloid fluids in the patient with hypovolemic shock? A) Decrease myocardial oxygen demand. B) Maximize oxygen-carrying capability. C) Increase capillary permeability. D) Restore circulating volume.

D) Restore circulating volume.

The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Infuse vasopressin (Pitressin) 0.01 units/min. d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.

E, D, C, A, B

A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. Which of the following is the pathophysiologic mechanism that results in septic shock? a. Bacterial toxins lead to vasodilation. b. Increased white blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. An increase of white blood cells leads to decreased red blood cell production and anemia.

a. Bacterial toxins lead to vasodilation.

The key to treatment of septic shock is finding the cause of the infection. Which of the following cultures are obtained before antibiotic therapy is initiated? (Select all that apply.) a. Blood cultures x 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. CBC with differential

a. Blood cultures x 2 b. Wound cultures c. Urine cultures d. Sputum cultures

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. Level of consciousness f. Urine output

A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. A pulmonary artery catheter is placed. Which of the following hemodynamic values would you expect to find? a. Cardiac output of 8 L/min b. Right atrial pressure of 17 mm Hg c. Pulmonary artery wedge pressure of 23 mm Hg d. Systemic vascular resistance of 1100

a. Cardiac output of 8 L/min

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Infuse drotrecogin-a (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.

a. Give normal saline IV at 500 mL/hr.

With anaphylactic shock, which mechanism results in a decreased cardiac output? a. Peripheral vasodilation b. Increased cardiac output c. Decreased alveolar ventilation d. Fluid retention resulting in congestive heart failure

a. Peripheral vasodilation

A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. d. Administer large volumes of lactated Ringers solution. e. Administer high-flow oxygen (100%) by non-rebreather mask.

a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. e. Administer high-flow oxygen (100%) by non-rebreather mask.

Which of the following clinical manifestations is not suggestive of systemic inflammatory response syndrome (SIRS)? a. Temperature of 37.5 C b. Heart rate of 95 beats/min c. Respiratory rate of 24 breath/min d. White blood cell (WBC) count of 15,000 cells/mm3

a. Temperature of 37.5 C

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. attach a cardiac monitor. c. obtain the blood pressure. d. check the level of consciousness.

a. administer oxygen.

A vasoconstrictor used to treat shock is a. adrenaline. b. Nipride. c. Dobutrex. d. adenosine.

a. adrenaline.

The most common site for sepsis and septic shock is a. the respiratory system. b. the gastrointestinal system. c. the genitourinary system. d. the circulatory system.

a. the respiratory system.

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 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

When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? a. BP 92/56 mm Hg b. Skin cool and clammy c. Apical pulse 118 beats/min d. Arterial oxygen saturation 91%

b. Skin cool and clammy

When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective? a. No heart murmur is audible. b. Skin is warm, pink, and dry. c. Troponin level is decreased. d. Blood pressure is 90/40 mm Hg

b. Skin is warm, pink, and dry.

Which medication is not recommended in the treatment of shock-related lactic acidosis? a. Glucose b. Sodium bicarbonate c. Vasoconstrictor d. Large quantity of crystalloids fluids

b. Sodium bicarbonate

Which information about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the heath care provider? a. The patients heart rate is 108 beats/min. b. The patient is complaining of chest pain. c. The patients peripheral pulses are weak. d. The patients urine output is 15 mL/hr

b. The patient is complaining of chest pain.

Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg

b. Urine output is 60 mL over the last hour.

Signs of hypovolemia in the trauma patient include a. distended neck veins. b. a decreased level of consciousness. c. bounding radial and pedal pulses. d. a widening pulse pressure.

b. a decreased level of consciousness.

The following therapies are prescribed by the health care provider for a patient who has respiratory distress and syncope after a bee sting. Which will the nurse administer first? a. normal saline infusion b. epinephrine (Adrenalin) c. dexamethasone (Decadron) d. diphenhydramine (Benadryl)

b. epinephrine (Adrenalin)

Profound weight loss in patients with SIRS or MODS is the result of a. hypometabolism. b. hypermetabolism. c. hyperglycemia. d. intolerance to enteral feedings

b. hypermetabolism.

When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Decreasing the room temperature to 68 F for a patient with neurogenic shock d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR

c. Decreasing the room temperature to 68 F for a patient with neurogenic shock

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 patients 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

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. Monitor breath sounds frequently.

To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse make? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Monitor stools for occult blood. d. Check for abdominal distention.

c. Monitor stools for occult blood.

After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride)

c. norepinephrine (Levophed).

When SIRS is the result of infection, it is called a. inflammation. b. anaphylaxis. c. sepsis. d. pneumonia.

c. sepsis.

A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first? a. Place the patient on continuous cardiac monitor. b. Draw blood to type and crossmatch for transfusions. c. Insert two 14-gauge IV catheters in antecubital space. d. Administer oxygen at 100% per non-rebreather mask

d. Administer oxygen at 100% per non-rebreather mask

Which medications are not effective in the immediate treatment of acute anaphylaxis? a. Epinephrine b. Vasopressors c. Diphenhydramine (Benadryl) IV d. Corticosteroids

d. Corticosteroids

Which of the following drugs promotes bronchodilation and vasoconstriction? a. Solu-Medrol b. Gentamicin c. Atropine d. Epinephrine

d. Epinephrine

During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation

d. New onset of confusion and agitation

Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation

d. Oxygen saturation

The nurse would identify which patients as being at increased risk for development of sepsis and septic shock? (Select all that apply) 1. A patient admitted from a nursing home for treatment of a stage 4 pressure ulcer 2. A patient with a ruptured viscus who is vomiting bright red blood 3. A patient who takes methotrexate for rheumatoid arthritis 4. A patient who sustained blunt trauma to the spinal cord 5. A patient being treated for aplastic anemia

1. A patient admitted from a nursing home for treatment of a stage 4 pressure ulcer 3. A patient who takes methotrexate for rheumatoid arthritis 5. A patient being treated for aplastic anemia

To assess if the renal system in a client diagnosed with multisystem failure is functioning properly, the nurse would expect to see urine output of: 1. 10 mL per hour. 2. 20 mL per hour. 3. 30 mL per hour. 4. 40 mL per hour.

3. 30 mL per hour.

The nurse is planning care for a client diagnosed with acute respiratory distress syndrome (ARDS)? Which of the following is not included in the management of this disorder? 1. Treating the underlying cause 2. Promoting gas exchange 3. Providing oxygen therapy 4. Promoting urine output

4. Promoting urine output.

The nurse realizes that a client, diagnosed with neurogenic shock, is at risk for developing: 1. skin breakdown. 2. sweating. 3. deep vein thrombosis. 4. infection.

3. deep vein thrombosis

The nurse is planning care for a client diagnosed with disseminated intravascular coagulation. Which of the following should be included in this plan of care? 1. Avoid intramuscular injections. 2. Provide adequate daily caloric intake. 3. perform range-of-motion exercises to all extremities twice a day. 4. Restrict fluids.

1. Avoid intramuscular injections.

A client is experiencing symptoms associated with distributive shock. What types of shock are included in this category? (Select all that apply.) 1. Neurogenic 2. Hypovolemic 3. Anaphylactic 4. Cardiogenic 5. Septic 6. Chronic

1. Neurogenic 3. Anaphylactic 5. Septic

The nurse is reviewing the diagnostic tests for a patient with an infection. Which test result would the nurse attribute to this diagnosis? 1. Potassium 2.9 mEq/L 2. Hemoglobin 8.5 gm/dL/ Hematocrit 25.2% 3. Decreased activated protein C 4. WBCs 5,000 cells/cubic mm

3. Decreased activated protein C

A patient in the critical care unit has developed shock. What symptom or symptom group does the nurse expect to assess in any type of shock? A) Tissue hypoxia B) Massive vasodilation C) Extreme blood loss D) Presence of enterotoxins

A) Tissue hypoxia

The patient in the ICU is being treated for left lower lobe pneumonia. What assessment findings by the nurse may indicate that the patient is developing systemic inflammatory response syndrome (SIRS)? Select all that apply. A) White blood cell count of 24,000/mm3 B) Respiratory rate of 24 C) Blood pressure of 100/60 D) Heart rate 96 E) Atrial fibrillation

A) White blood cell count of 24,000/mm3 B) Respiratory rate of 24 D) Heart rate 96

The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? a. The patients IV infusion site is cool and pale. b. The patient has warm, dry skin on the extremities. c. The patient has an apical pulse rate of 58 beats/min. d. The patients urine output has been 28 mL over the last hour.

a. The patients IV infusion site is cool and pale.

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine? a. The patients central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min. d. The patient has had no urine output since being admitted.

a. The patients central venous pressure is 3 mm Hg.

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.

Shock syndrome can best be described as a a. physiologic state resulting in hypotension and tachycardia. b. generalized systemic response to inadequate tissue perfusion. c. degenerative condition leading to death. d. condition occurring with hypovolemia that results in irreversible hypotension.

b. generalized systemic response to inadequate tissue perfusion.

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

Hypovolemic shock that results from an internal shifting of fluid from the intravascular space to the extravascular space is known as a. absolute hypovolemia. b. distributive hypovolemia. c. relative hypovolemia. d. compensatory hypovolemia.

c. relative hypovolemia.

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 client experiencing hypovolemic shock. Which of the following interventions would be appropriate for this client? (Select all that apply.) 1. Monitor intravenous fluid replacement 2. Monitor vital signs 3. Assess for manifestations of fluid overload 4. Monitor white blood cell count and hemoglobin and hematocrit levels 5. Position for comfort 6. Assist to a sitting position

1. Monitor intravenous fluid replacement 2. Monitor vital signs 3. Assess for manifestations of fluid overload 4. Monitor white blood cell count and hemoglobin and hematocrit levels 5. Position for comfort

The nurse is caring for a client who has sustained multiple injuries from a motor vehicle accident. The nurse realizes that the client will have a release of stress hormones that are useful for all of the following EXCEPT: 1. preventing loss of fluids. 2. preventing hypotension. 3. preventing infection. 4. preventing ingestion of food.

4. preventing ingestion of food.

The nurse is determining if a client is experiencing chronic inflammation. Which of the following are indications for this type of inflammation? (Select all that apply.) 1. Chronic elevation of white blood cells 2. Low-grade fever 3. Pain 4. Scar formation 5. Low blood pressure 6. Hematuria

1. Chronic elevation of white blood cells 2. Low-grade fever 3. Pain 4. Scar formation

The nurse is assessing a client for systemic inflammatory response syndrome (SIRS). Which of the following disease processes are associated with this syndrome? (Select all that apply.) 1. Infection 2. Pancreatitis 3. Ischemia 4. Trauma 5. Massive transfusions 6. Heart failure

1. Infection 2. Pancreatitis 3. Ischemia 4. Trauma 5. Massive transfusions

The nurse would be most alert for assessment findings of hypovolemic shock in which patient? 1. Patient who had a DVT after a surgical procedure 2 years ago 2. Patient 6 hours postmastectomy 3. Patient with coronary atherosclerosis who takes 81 mg of aspirin daily 4. Patient sustaining a transmural myocardial infarction 2 days ago

2. Patient 6 hours postmastectomy

A patient who takes a beta adrenergic blocker is at risk of developing shock after an accident. The nurse is aware that the patients medication use may alter which assessment finding associated with shock? 1. Tachycardia 2. Declining mental status 3. Cyanosis 4. Tachypnea

1. Tachycardia

A client is diagnosed with septic shock. The nurse realizes that the major cause of this type of shock is: 1. gram-negative bacteria. 2. gram-positive bacteria. 3. fungi. 4. viruses.

1. gram-negative bacteria.

The nurse plans to administer normal saline to a patient with systemic inflammatory response syndrome (SIRS) and hypotension. At which rate would the nurse anticipate administering this fluid? 1. 20 mL/hr 2. 500 mL/hr 3. 100 mL/hr 4. 0.05 mL/kg/hr

2. 500 mL/hr

The nurse is caring for a patient with MODS secondary to septic shock whose urine output was 10 mL for the last 2 hours. Temperature is 97 degrees, pulse is 124 and thready, and BP is 88/48. Which order is the current priority? 1. Place the patient on a warming blanket. 2. Administer isotonic fluids at 20 mL/kg/hr. 3. Draw blood for BUN and creatinine. 4. Place the patient in a kinetic bed.

2. Administer isotonic fluids at 20 mL/kg/hr.

The nurse, caring for a client diagnosed with shock, realizes that the stage in which the body attempts to remedy the problem by initiating the homeostatic mechanism would be? 1. Initial stage 2. Compensatory stage 3. Multiple organ failure stage 4. Refractory stage

2. Conpensatory stage

A patient admitted to the emergency department after a traumatic injury is becoming more and more lethargic and hard to arouse. Periods of apnea are increasing. To protect the patients airway, the nurse should prepare to assist with which intervention? 1. Monitoring oxygen saturation 2. Endotracheal intubation 3. Assessment of breath sounds 4. Asking the patient if it is becoming difficult to breathe

2. Endotracheal intubation

A client experiences a bee sting, complains of difficulty breathing, and shows sign of hypoxia and hypotension. The nurse realizes these are signs of anaphylactic shock, and she should do which of the following first? 1. Get a medical alert bracelet for the patient. 2. Give epinephrine intravenously or via endotracheal tube. 3. Check with the family for a history. 4. Admit the client through the admitting department.

2. Give epinephrine intravenously or via endotracheal tube.

The critical care nurse is delivering a peer lecture on guidelines for the management of SIRS and severe sepsis. Which intervention would the nurse describe as improving outcomes in septic shock? 1. Use bicarbonate for pH of 7.30. 2. Keep mechanically ventilated patients flat in bed. 3. Maintain blood glucose lower than 150 mg/dL. 4. Initiate antibiotic therapy within 4 hours of diagnosis.

3. Maintain blood glucose lower than 150 mg/dL.

The nurse will plan which interventions to reduce metabolic demands in a patient with multiple organ dysfunction syndrome (MODS)? 1. Provide skin care and positioning to prevent breakdown. 2. Use meticulous hand hygiene and aseptic technique for procedures. 3. Place the patient on a high-fat diet to increase energy. 4. Administer antipyretics for fever

4. Administer antipyretics for fever

The nurse is caring for a patient with endocarditis who is receiving penicillin. The nurse should be particularly attentive to recognize early symptoms of which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Septic 4. Anaphylactic

4. Anaphylactic

A patient developed septic shock related to cancer chemotherapy. This morning the nurse assessed a change in the patients mental status. The nurses primary concern would focus on which possible etiology for this change? 1. Anxiety about and fear of death 2. Metastasis of underlying cancer 3. A result of chemotherapy 4. Decreased tissue oxygenation

4. Decreased tissue oxygenation

A patient who was stabbed in the abdomen has received fluid resuscitation of 2 liters over the last hour. Which finding would the nurse evaluate as indicating this intervention has been ineffective? 1. Patient complaints of abdominal pain 2. Patients request to see a priest 3. Urine output of 45 mL for this hour 4. Heart rate 142 and NSR

4. Heart rate 142 and NSR

A client is diagnosed with cardiogenic shock. The nurse should plan interventions to address which of the following potential complications of this disorder? 1. Pulmonary embolism 2. Deep vein thrombosis 3. Renal failure 4. Myocardial infarction

4. Myocardial infarction

A leading cause of death in critically ill patients is sepsis and septic shock. What nursing intervention is most directed toward preventing this life-threatening complication? A) Strict adherence to hand hygiene protocols B) Prompt initiation of isolation protocols C) Patient and family preventive teaching D) Sterile technique for care of intravenous sites

A) Strict adherence to hand hygiene protocols

The nurse understands that which of the following patients in the hospital is at the greatest risk for cardiogenic shock? A) The 76-year-old male patient with a history of diabetes mellitus and previous myocardial infarction (MI) B) The 42-year-old male who has mitral valve prolapse with a left ventricular ejection fraction of 65% C) The 52-year-old female with a recent small anteroseptal wall MI D) The 84-year-old female with hypertension

A) The 76-year-old male patient with a history of diabetes mellitus and previous myocardial infarction (MI)

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 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 patients 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 is concerned that a client will develop neurogenic shock when which of the following is assessed? 1. Fractured left lower extremity 2. Spinal cord injury at T1 3. Jugular vein distention 4. Sluggish bowel sounds

2. Spinal cord injury at T1

A client is diagnosed with failure of the left ventricle to provide adequate delivery of oxygen to the body tissues due to a weakened forward pumping function of the heart. The nurse realizes this client is experiencing: 1. anaphylactic reaction. 2. cardiogenic shock. 3. hypovolemia. 4. metabolic acidosis.

2. cardiogenic shock.

According to standard definitions, which patient would the nurse describe as being in septic shock? 1. A patient with community-acquired pneumonia who has developed respiratory failure 2. A patient who has burns over 40% of the body and is febrile 3. A patient with an infection whose blood pressure is 84/52 after 4 liters of saline were administered intravenously 4. A patient with a WBC count of 22,000 and fever

3. A patient with an infection whose blood pressure is 84/52 after 4 liters of saline were administered intravenously

Which patients would the nurse identify as being at increased risk for the development of hypovolemic shock? (Select all that apply) 1. A patient with systemic lupus erythematosus 2. A patient who had a myocardial infarction 3. A patient with cirrhosis, ascites, and anasarca 4. A patient who was the unrestrained front-seat passenger in a multivehicle car crash 5. Patient with ruptured abdominal aortic aneurysm

3. A patient with cirrhosis, ascites, and anasarca 4. A patient who was the unrestrained front-seat passenger in a multivehicle car crash 5. Patient with ruptured abdominal aortic aneurysm

The nurse is caring for a patient with septic shock and MODS. A family member tearfully tells the nurse, The doctor said my mothers organs are shutting down. How did that happen? What is the nurses best response? 1. The infection attacks and destroys each organ, causing it to fail. 2. Fever damages the brain, which controls all organs. 3. Deprivation of oxygen during shock causes organs to fail to function properly. 4. The stress of illness has overwhelmed your loved one.

3. Deprivation of oxygen during shock causes organs to fail to function properly.

A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. The medical management of the patients condition is aimed toward a. limiting fluids to minimize the possibility of congestive heart failure. b. finding and eradicating the cause of infection. c. discontinuing invasive monitoring as a possible cause of sepsis. d. administering vasodilator substances to increase blood flow to vital organs.

b. finding and eradicating the cause of infection.

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2 F (38.4 C)

c. Apical heart rate 48 beats/min

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

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.

An 80-year-old patient is being admitted from a nursing home for treatment of septic shock. Which assessment finding should the nurse investigate as the most likely source of the sepsis? 1. A red, flat rash in the perineal area 2. History of exposure to a daughter who is receiving chemotherapy 3. Report that several patients at the nursing home have scabies 4. An indwelling urinary catheter inserted 3 days ago by nursing home personnel

4. An indwelling urinary catheter inserted 3 days ago by nursing home personnel

A patient in shock is receiving norepinephrine by continuous infusion. For which outcome would the nurse monitor to evaluate the effectiveness of this medication? 1. Cardiac enzymes 2. Reduced apical heart rate 3. Reduction in bleeding 4. Blood pressure

4. Blood pressure

A patient has developed severe cardiogenic shock and is on a mechanical ventilator. The family asks why the patients hands feel so cold. What is the nurses best response? 1. We keep the intensive care unit cool to reduce patients metabolic rates. 2. The patient has developed a fever and chills. 3. This happens frequently to patients in shock states. 4. Blood vessels constrict in shock, which takes the blood away from hands and feet.

4. Blood vessels constrict in shock, which takes the blood away from hands and feet.

A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg. d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

a. Infuse normal saline at 250 mL/hr.

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 patients 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.

Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patients serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient has crackles throughout both lung fields. d. The patients extremities are cool and pulses are weak

a. The patients serum creatinine level is elevated.