Shock and Multiple Organ Dysfunction Syndrome

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first?

100% oxygen via a nonrebreather mask

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?

70%

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers

A continuous infusion of total parenteral nutrition

23. Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's heart rate is 110 beats/minute.

ANS: B Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next

Administers oxygen by nasal cannula at 2 liters per minute

When vasoactive medications are administered, the nurse must monitor vital signs at least how often? a) 30 minutes b) Hourly c) 15 minutes d) 45 minutes

C (15 minutes)

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?

Compensatory stage

Which of the following is a clinical characteristic of neurogenic shock? a) Cool skin b) Tachycardia c) Moist skin d) Bradycardia

D (Bradycardia)

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:

MI

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 nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? a) The client with pneumonia in the left lower lobe of the lung b) The client with testicular cancer who is receiving intravenous chemotherapy c) The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs) d) The client with a BMI of 25 who has lost 3 pounds as the result of vomiting

The client with testicular cancer who is receiving intravenous chemotherapy

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."

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.

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.

- Vital signs - Skin color - Urine output - Peripheral pulses

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 is calculating a patient's mean arterial pressure (MAP). What is the patient's MAP, if the blood pressure is 110/70 mm Hg?

83

The nurse is 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. Skin cool and clammy b. Heart rate of 118 beats/min c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

A (Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status.)

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A full liquid diet b) Isotonic enteral nutrition every 6 hours c) A continuous infusion of total parenteral nutrition d) An infusion of crystalloids at an increased rate of flow

A continuous infusion of total parenteral nutrition

For which of the following patients in shock would a nurse observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment? a) A patient with an overwhelming bacterial infection b) A patient who has lost blood during a child birth c) A patient who has had an overdose of opioids d) A patient who has had severe allergic reaction to a bee sting

A patient with an overwhelming bacterial infection

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

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) A slow and imperceptible pulse b) A weak and thready pulse c) A slow but steady pulse d) A rapid, bounding pulse

A rapid, bounding pulse

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?

A rapid, bounding pulse A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.

15. 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 intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

ANS: A Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well. DIF: Cognitive Level: Apply (application) REF: 1600 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. 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.

ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate. DIF: Cognitive Level: Apply (application) REF: 1596 TOP: Nursing Process: Implementation

18. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. obtain a 12-lead electrocardiogram (ECG). c. obtain the blood pressure. d. check the level of consciousness.

ANS: A The initial actions of the nurse are focused on the ABCsairway, breathing, and circulationand administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration. DIF: Cognitive Level: Apply (application) REF: 1597 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

2. Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

ANS: A, B, C, D Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? Use aseptic technique when caring for invasive lines or devices. Ambulate postoperative patients as soon as possible after surgery. Remove indwelling urinary catheters as soon as possible after surgery. Advocate for parenteral nutrition for patients who cannot take oral feedings. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

ANS: A, B, C, E Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS. DIF: Cognitive Level: Analyze (analysis) REF: 1605 TOP: Nursing Process: Planning

1. A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

ANS: A, B, D, E All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.

9. Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. DIF: Cognitive Level: Apply (application) REF: 1598 TOP: Nursing Process: Evaluation

22. The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? Start a normal saline infusion. Give epinephrine (Adrenalin). Start continuous ECG monitoring. Give diphenhydramine (Benadryl).

ANS: B Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed. DIF: Cognitive Level: Apply (application) REF: 1601 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

20. A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? Insert two large-bore IV catheters. Initiate continuous electrocardiogram (ECG) monitoring. Provide oxygen at 100% per non-rebreather mask. Draw blood to type and crossmatch for transfusions.

ANS: C The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize oxygen delivery have been implemented. DIF: Cognitive Level: Apply (application) REF: 1597 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

25. After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment Laboratory Data Vital Signs · Petechiae noted on chest and legs · Crackles heard bilaterally in lung bases · No redness or swelling at central line IV site · Blood urea nitrogen (BUN) 34 mg/Dl · Hematocrit 30% · Platelets 50,000/ μL · Temperature 100°F (37.8°C) · Pulse 102/min · Respirations 26/min · BP 110/60 mm Hg · O2 saturation 93% on 2L O2 via nasal cannula a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate.

ANS: C The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.

21. A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

ANS: C The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

16. When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? 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. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock

ANS: D Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Apply (application) REF: 1590 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation

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.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a) Administers oxygen by nasal cannula at 2 liters per minute b) Calls the Rapid Response Team c) Re-assesses the vital signs d) Contacts the admitting physician

Administers oxygen by nasal cannula at 2 liters per minute

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits

Adventitious breath sounds

Which of the following colloids is expensive but rapidly expands plasma volume? a) Lactated Ringer's b) Dextran c) Albumin d) Hypertonic saline

Albumin

Which type of shock occurs from an antigen-antibody response? a) Neurogenic b) Anaphylactic c) Septic d) Cardiogenic

Anaphylactic

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a) Right ventricular wall b) Aorta c) Brachial artery d) Radial artery

Aorta

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

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? a) Diabetes mellitus b) Unstable angina pectoris c) Hypertension d) Aortic insufficiency

Aortic insufficiency

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a) Right ventricular wall b) Aorta c) Brachial artery d) Radial artery

B (Aorta)

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles b. Heart rate 45 beats/min c. Cool, clammy extremities d. Temperature 101.2°F (38.4°C)

B (Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.)

Morphine sulfate has which of the following effects on the body? a) No effect on preload or afterload b) Reduces preload c) Increases preload d) Increases afterload

B (Reduces preload)

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.

Which of the following is a clinical characteristic of neurogenic shock? a) Cool skin b) Tachycardia c) Moist skin d) Bradycardia

Bradycardia

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? a) Hormone antagonist drugs b) Antimetabolite drugs c) Adrenergic drugs d) Anticholinergic drugs

C (Adrenergic drugs)

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? a) Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids b) Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing d) Rubbing the hands together with antiseptic solution until dry when exiting the client's room

C (Hanging tape on the bedside table when changing a wet-to-dry sterile dressing.)

The nurse anticipates that a patient who is immunosuppressed is at the greatest risk for developing which of the following types of shock? A. Cardiogenic shock B. Anaphylactic shock C. Septic shock D. Anaphylastic shock

C (Septic shock)

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? a) Cardiogenic b) Anaphylactic c) Septic d) Neurogenic

C (Septic)

You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately? A. The client feels restless and hungry. B. The client exhibits an increased urinary output. C. The client's heart rate is greater than 90 beats per minute. D. The client's heart rate is less than 60 beats per minute.

C (The client's heart rate is greater than 90 beats per minute.)

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment Laboratory Data Vital Signs · Petechiae noted on chest and legs · Crackles heard bilaterally in lung bases. · No redness or swelling at central line IV site. · Blood urea nitrogen (BUN) 34mg/Dl · Hematocrit 30% · Platelets 50,000/μL · Temperature 100°F (37.8°C) · Pulse 102/min · Respirations 26/min · BP 110/60 mm Hg · O2 saturation 93% on 2L O2 via nasal cannula a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate.

C (The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.)

When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor for symptoms of: A.Hyperthermia B.Pain C.Pulmonary edema D.Tachycardia

C (The nurse should monitor for circulatory overload and pulmonary edema when large volumes of fluids are administered intravenously. Hypothermia may occur with large volumes of fluid that are not warmed. Pain would.)

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: a) Bilateral pedal pulses are 1+. b) Vesicular breath sounds are audible in the lung periphery. c) The right foot is cooler than the left foot. d) The balloon deflates prior to systole.

C (The right foot is cooler than the left foot.)

A 74-year-old male client who is suffering a myocardial infarction is transported to the ED by ambulance. This client is at greatest risk for developing which type of shock?

Cardiogenic

Older adults are more likely to develop which type of shock?

Cardiogenic shock

Which of the following type of shock are older adults more likely to develop? a) Septic shock b) Neurogenic shock c) Cardiogenic shock d) Anaphylactic shock

Cardiogenic shock

In which type of shock does the patient experience a mismatch of blood flow to the cells? a) Cardiogenic b) Circulatory c) Septic d) Hypovolemic

Circulatory

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock?

Circulatory (distributive) Vasodilatation, a prominent characteristic of circulatory/distributive shock, increases the space in the vascular bed. Central blood flow is reduced because peripheral vascular or interstitial areas exceed their usual capacity. Vasodilation is not a major component of cardiogenic, hypovolemic, or obstructive shock.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:

Constrict blood vessels in the cardiorespiratory system.

Which positioning strategy should be utilized for the patient diagnosed with hypovolemic shock? a) Semi-Fowler's b) Prone c) Supine d) Modified Trendelenburg

D (Modified Trendelenburg)

As the body tries to adjust to accommodate injury (and thus avoid shock), many physical responses are expected. When the pathophysiological compensations are not sufficient, which stage of shock does the client experience? a) Compensation stage b) Catecholamine stage c) Irreversible stage d) Progressive stage

D (Progressive stage)

The nurse assesses the patient for the negative effect of IV nitroglycerin (Tridil) for shock management which is:

Decreased blood pressure.

The nurse caring for a patient post epidural anesthesia notices that the patient is beginning to evidence symptoms of shock. The nurse assesses the patient for what type of shock?

Distributed

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. A neighbor calls 911. Which nursing action is helpful while waiting for the ambulance?

Elevate the legs higher than the heart.

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance?

Elevate the legs higher than the heart.

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 a) Encourage the family to touch and talk to the client. b) Inform the family that everything is being done to assist with the client's survival. c) Open up discussion among the family members about nursing home placement. d) Contact a spiritual advisor to provide comfort to the family.

Encourage the family to touch and talk to the client.

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. The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

A patient presents to the emergency department after being stung by a bee, complaining of difficulty breathing. What vasoconstrictive medication should be given at this time?

Epinephrine

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? a) Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids b) Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing d) Rubbing the hands together with antiseptic solution until dry when exiting the client's room

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

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Multiple sclerosis b) Myocardial infarction c) Diabetes d) Head injury

Head injury

A client has developed shock as the result of the MVA. His treatment is focused on preventing the development of more than one type of shock and to minimize the effects of the type of shock he is demonstrating. Which of the following is NOT a category of shock? a) Hepatic b) Circulatory c) Cardiogenic d) None of the options are correct

Hepatic

You are caring for a client in the compensation stage of shock. You know that in this stage of shock epinephrine and norepinephrine are released into the circulation. What positive effect does this have on your client?

Increase myocardial contractility

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?

Increase the force of myocardial contraction

You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client?

Increases myocardial contractility

You are caring for a client in the compensation stage of shock. You know that in this stage of shock epinephrine and norepinephrine are released into the circulation. What positive effect does this have on your client? a) Decreases blood return to the heart b) Decreases carbon dioxide exchange c) Increases myocardial contractility d) Contracts bronchioles

Increases myocardial contractility

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

Intubation and mechanical ventilation

The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? a) It begins when peripheral blood flow is inadequate. b) It causes respiratory distress syndrome. c) It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. d) It is a component of any trauma.

It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.

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: a) Positive increase in the fluid balance ratio b) Decreased pulse rate to 110 beats/minute c) Jugular venous distention d) Vesicular breath sounds

JVD

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 hen administering large volumes of fluid replacement, the nurse monitors the client for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. The nurse assesses for jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. The client should exhibit vesicular breath sounds.

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.

The nurse is caring for a patient newly diagnosed with sepsis. The patient has a serum lactate level of 6 mmol/L and fluid resuscitation has been initiated. Which of the following indicates that the fluid resuscitation received by the patient is adequate?

Mean arterial pressure (MAP) of 70 mm Hg

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?

Myocardial depression The body's inability to meet increased oxygen requirements produces ischemia, and biochemical mediators cause myocardial depression. This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin.

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?

Narrowed pulse pressure

Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock?

Neurogenic

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: a) Oxygen at 2 L/min by nasal cannula b) Dopamine (Intropin) intravenous solution c) NS at 60 mL/hr via an intravenous line d) Morphine 2 mg intravenously

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.

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?

Septic

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? a) Cardiogenic b) Anaphylactic c) Septic d) Neurogenic

Septic

The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock?

Septic

Which type of shock is caused by an infection? a) Septic b) Hypovolemic c) Cardiogenic d) Anaphylactic

Septic

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.

When a patient is in the compensatory stage of shock which of the following symptoms occurs? a) Tachycardia b) Bradycardia c) Urine output of 45 cc/hour d) Respiratory acidosis

Tachycardia

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 client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: a) Bilateral pedal pulses are 1+. b) Vesicular breath sounds are audible in the lung periphery. c) The right foot is cooler than the left foot. d) The balloon deflates prior to systole.

The right foot is cooler than the left foot.

When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal?

Treat the oxygenation needs of the heart muscle

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

Urinary output Vital signs Mental status Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. The patient receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema.

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 incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques (Fried et al., 2011). Inserting an indwelling catheter would increase the risk of infection and thus of septic shock, not decrease it. Hand hygiene is more of a priority than administering prophylactic antibiotics. Masks would not prevent many types of infections.

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

anaphylactic

A client who is suffering a myocardial infarction is transported to the ED by ambulance. This client is at greatest risk for developing which type of shock?

cardiogenic shock

A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing?

decompensation stage Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. This client's symptoms, particularly the dropping BP, indicate the decompensation stage. During the compensation stage of shock, physiologic mechanisms attempt to stabilize the spiraling consequences. During the irreversible stage, the client no longer responds to medical interventions, and multiple systems begin to fail. Cardiogenic shock is a type of shock.

A nurse knows that the major clinical use of dobutamine (Dobutrex) is to: a) prevent sinus bradycardia. b) increase cardiac output. c) treat hypertension. d) treat hypotension.

increase cardiac output.

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?

multiple organ failure

The nurse anticipates that a patient who is immunosuppressed is at the greatest risk for developing which of the following types of shock?

sepetic

For which of the following patients in shock would a nurse observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment? a) A patient with an overwhelming bacterial infection b) A patient who has lost blood during a child birth c) A patient who has had an overdose of opioids d) A patient who has had severe allergic reaction to a bee sting

A (A patient with an overwhelming bacterial infection.)

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a) Administers oxygen by nasal cannula at 2 liters per minute b) Calls the Rapid Response Team c) Re-assesses the vital signs d) Contacts the admitting physician

A (Administers oxygen by nasal cannula at 2 liters per minute.)

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: A. Encourage the family to touch and talk to the client. B. Inform the family that everything is being done to assist with the client's survival. C. Open up discussion among the family members about nursing home placement. D. Contact a spiritual advisor to provide comfort to the family.

A (Encourage the family to touch and talk to the client.)

A client has developed shock as the result of the MVA. His treatment is focused on preventing the development of more than one type of shock and to minimize the effects of the type of shock he is demonstrating. Which of the following is NOT a category of shock? a) Hepatic b) Circulatory c) Cardiogenic d) None of the options are correct

A (Hepatic)

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? A. Lactated ringer's B. Sodium Chloride 0.9% C. 5% dextrose solution D. Hypertonic

A (Lactated ringer's)

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

A (The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock.)

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: a) Oxygen at 2 L/min by nasal cannula b) Dopamine (Intropin) intravenous solution c) NS at 60 mL/hr via an intravenous line d) Morphine 2 mg intravenously

A (Oxygen at 2 L/min by nasal cannula)

2. A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg. d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

ANS: A The patients elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the patient. DIF: Cognitive Level: Apply (application) REF: 1589 TOP: Nursing Process: Planning

3. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles c. Cool, clammy extremities b. Heart rate 45 beats/min d. Temperature 101.2°F (38.4°C)

ANS: B Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

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

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first? A) Obtain the name and information of the allergic substance. B) Administer an epinephrine injection. C) Notify a physician. D) Call 911.

B (Administer an epinephrine injection.)

Which type of shock occurs from an antigen-antibody response? a) Neurogenic b) Anaphylactic c) Septic d) Cardiogenic

B (Anaphylactic)

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

B (Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.)

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

B (Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.)

In which type of shock does the patient experience a mismatch of blood flow to the cells? a) Cardiogenic b) Circulatory c) Septic d) Hypovolemic

B (Circulatory)

Which stage of shock is characterized by a normal blood pressure? A.Initial B.Compensatory C.Progressive D.Irreversible

B (In the compensatory stage of shock, the BP remains within normal limits. In the second stage of shock, the mechanisms that regulate BP can no longer compensate and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline. The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Despite treatment, BP remains low.)

A nurse knows that the major clinical use of dobutamine (Dobutrex) is to: a) prevent sinus bradycardia. b) increase cardiac output. c) treat hypertension. d) treat hypotension.

B (Increase cardiac output.)

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? a) The client with pneumonia in the left lower lobe of the lung b) The client with testicular cancer who is receiving intravenous chemotherapy c) The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs) d) The client with a BMI of 25 who has lost 3 pounds as the result of vomiting

B (The client with testicular cancer who is receiving intravenous chemotherapy.)

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

B (The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented.)

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A full liquid diet b) Isotonic enteral nutrition every 6 hours c) A continuous infusion of total parenteral nutrition d) An infusion of crystalloids at an increased rate of flow

C (A continuous infusion of total parenteral nutrition.)

Which of the following colloids is expensive but rapidly expands plasma volume? a) Lactated Ringer's b) Dextran c) Albumin d) Hypertonic saline

C (Albumin)

Which of the following type of shock are older adults more likely to develop? a) Septic shock b) Neurogenic shock c) Cardiogenic shock d) Anaphylactic shock

C (Cardiogenic shock)

You are caring for a client in the compensation stage of shock. You know that in this stage of shock epinephrine and norepinephrine are released into the circulation. What positive effect does this have on your client? a) Decreases blood return to the heart b) Decreases carbon dioxide exchange c) Increases myocardial contractility d) Contracts bronchioles

C (Increases myocardial contractility)

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? a. Prone b. Semi-Fowler's c. Modified Trendelenburg d. Supine

C (Modified Trendelenburg)

Which of the following would be a pulse pressure indicative of shock? a) 130/90 b) 120/90 c) 100/60 d) 90/70

D (90/70)

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain. a. a dopamine infusion. b. a hypothermia blanket. c. lactated Ringer's solution. d. two 16-gauge IV catheters.

D (A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.)

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) A slow and imperceptible pulse b) A weak and thready pulse c) A slow but steady pulse d) A rapid, bounding pulse

D (A rapid, bounding pulse)

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? a) Diabetes mellitus b) Unstable angina pectoris c) Hypertension d) Aortic insufficiency

D (Aortic insufficiency)

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

D (Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.)

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Multiple sclerosis b) Myocardial infarction c) Diabetes d) Head injury

D (Head injury)

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? A. Codeine B. Demerol C. Dilaudid D. Morphine

D (Morphine)

A 57-year-old client has been brought to your ED via squad. He is unresponsive, and his wife reports his symptoms of elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. His labs show an elevated WBC; cultures are forthcoming. You suspect which of the following may be the cause of the client's present condition?

Septic

14. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate 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 patients extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

ANS: A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patients diagnosis of cardiogenic shock. DIF: Cognitive Level: Apply (application) REF: 1605 TOP: Nursing Process: Assessment

When a patient is in the compensatory stage of shock which of the following symptoms occurs? a) Tachycardia b) Bradycardia c) Urine output of 45 cc/hour d) Respiratory acidosis

A (Tachycardia)

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Decreased bowel sounds c. Heart rate 112 beats/min d. Pale, cool, and dry extremities

A (The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.)

15. A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.

ANS: A Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

A, B, C, D (Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.)

8. The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain a. hypothermia blanket. b. lactated Ringers solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.

ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringers solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool. DIF: Cognitive Level: Apply (application) REF: 1597 TOP: Nursing Process: Planning

6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. c. Check stools for occult blood. b. Ask the patient about nausea. d. Palpate for abdominal tenderness.

ANS: C Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? a) It begins when peripheral blood flow is inadequate. b) It causes respiratory distress syndrome. c) It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. d) It is a component of any trauma.

C (It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.)

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: a) Positive increase in the fluid balance ratio b) Decreased pulse rate to 110 beats/minute c) Jugular venous distention d) Vesicular breath sounds

C (Jugular venous distention)

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? A. Increase in diastolic pressure. B. Decrease in respiratory rate. C. Narrowed pulse pressure. D. Increase in systolic pressure

C (Narrowed pulse pressure.)

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. obtain the blood pressure. b. check the level of orientation. c. administer supplemental oxygen. d. obtain a 12-lead electrocardiogram.

C (The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.)

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

20. A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

ANS: B The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented.

3. A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles. b. Cool, clammy extremities. c. Apical heart rate 45 beats/min. d. Temperature 101.2 F (38.4 C).

ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock. DIF: Cognitive Level: Understand (comprehension) REF: 1590 TOP: Nursing Process: Assessment

18. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. obtain the blood pressure. b. check the level of orientation. c. administer supplemental oxygen. d. obtain a 12-lead electrocardiogram.

ANS: C The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.

A (Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.)

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

A, B, D, E (All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.)

17. The nurse is 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. Skin cool and clammy c. Blood pressure of 92/56 mm Hg b. Heart rate of 118 beats/min d. O2 saturation of 93% on room air

ANS: A Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status.

14. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

ANS: A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock.

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

ANS: A, B, D, E All of the actions are appropriate except to give large volumes of lactated Ringers solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringers solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate. DIF: Cognitive Level: Apply (application) REF: 1602 TOP: Nursing Process: Implementation

24. After change-of-shift report in the progressive care unit, who should the nurse care for first? Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

ANS: B Antibiotics should be administered within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS) and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension. DIF: Cognitive Level: Analyze (analysis) REF: 1600 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment

10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

ANS: B Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock. DIF: Cognitive Level: Apply (application) REF: 1589 TOP: Nursing Process: Implementation

11. Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since being admitted.

ANS: B Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

9. Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

17. The nurse is 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. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute

ANS: B Because patients in the early stage of septic shock have warm and dry skin, the patients cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patients status. DIF: Cognitive Level: Apply (application) REF: 1594 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

ANS: B Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

8. The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain a. a dopamine infusion. c. lactated Ringer's solution. b. a hypothermia blanket. d. two 16-gauge IV catheters.

ANS: D A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

13. Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate c. Blood pressure b. Orientation d. Oxygen saturation

ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

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

ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock. DIF: Cognitive Level: Apply (application) REF: 1602 TOP: Nursing Process: Evaluation