Shock, Sepsis, & MODS- Critical Care- IV semester

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

ANS: A A high PAOP and a low cardiac index are findings consistent with cardiogenic shock. Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.

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

ANS: A Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is inappropriate without further attempts using different modalities.

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm5

ANS: A Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are high and would not indicate an appropriate response to therapy.

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

ANS: A Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated.

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

ANS: A Given the patient's diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration. Universal precautions, fall precautions, and application of heel protectors are appropriate interventions but are not the immediate priority.

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

ANS: A In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.

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

ANS: A Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia.

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

ANS: A The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not "beat" for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.

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

ANS: A The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.

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

ANS: A The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical situation.

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

ANS: A Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.

The nurse is caring for a 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

ANS: A, C, F The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response and respirations do not assess perfusion.

The nurse has just completed administration of a 500 mL bolus of 0.9% normal saline in a patient with hypovolemic shock. 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.

ANS: B Assessed vital signs and hemodynamic values indicate decreased circulating volume. The patient has not responded appropriately to therapy aimed at increasing circulating volume. Additional intervention is needed because response to therapy is not appropriate, values are abnormal, and timely intervention is critical for a patient with low circulating blood volume.

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

ANS: B Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins. Hemoglobin and hematocrit results indicate hemodilution. Given the clinical scenario, there is no evidence to support the need for a blood transfusion and no evidence of fluid overload. Although administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third-spacing of fluid, this fact does not support the hemoglobin and hematocrit results.

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

ANS: B Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.

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

ANS: B Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse. A blood pressure of 100/60 mm Hg, heart rate of 110 beats/min, and a CVP of 8 mm Hg are adequate and do not require immediate intervention.

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a. Furosemide 20 mg intravenous (IV) every 4 hours as needed for CVP greater than or equal to 20 mm Hg b. Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain c. Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as needed for CI less than 2 L/min/m2 d. Dopamine infusion at a rate of 5 to 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

ANS: B The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order options.

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 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone 125 mg intravenously d. Ranitidine 50 mg intravenously

ANS: B The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone, are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.

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

ANS: B Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit, which this patient displays. The nurse should question the use of the dopamine infusion. All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

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

ANS: C Dobutamine is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states, improving overall cardiac performance. The patient's cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart. There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram. Assessment of hourly urine output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario.

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

ANS: C Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.

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

ANS: C Given the acute nature of the patient's blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient's blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 94.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via face mask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)

ANS: C Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patient's oxygen saturation is 95% on room air with an adequate respiratory rate. The application of 100% oxygen via face mask is not indicated. The patient's heart rate is adequate to support a normal blood pressure.

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

ANS: C Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body temperature is a priority. While administration of pain management, repositioning the patient every 2 hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario.

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

ANS: C Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa. Monitoring intake and output, frequent turning, and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission.

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

ANS: C The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.

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

ANS: D Adequate urine output of at least 0.5 mL/kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.

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

ANS: D A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.

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

ANS: D As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In the early stages of septic shock, cardiac output is high.

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

ANS: D As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All other listed arterial blood gas values are within normal limits.

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. 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

ANS: D Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario.

The nurse has been administering 0.9% normal saline intravenous fluids 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

ANS: D Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock.

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.

ANS: D Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.

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

ANS: D, E, F In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction, interventions used, and patient response to treatment are documented although this occurs after immediate action has been taken. Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the infusion further increases the likelihood of worsening the transfusion reaction.

A client is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this client for when administering the infusion? Select all that apply. A) Muscle spasms B) Tachycardia C) Confusion D) Gastrointestinal bleeding E) Disorientation

Answer: A, B, C, E Explanation: Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the healthcare provider. Gastrointestinal bleeding is not an adverse effect of this medication.

The nurse is concerned that a client is demonstrating early signs of hypovolemic shock. Which assessment findings support the nurse's concern? Select all that apply. A) Slight increase in pulse B) Prolonged capillary refill time C) Rapid weak pulse D) Normal respirations E) Normal blood pressure

Answer: A, B, D, E Explanation: Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a characteristic of the irreversible stage of hypovolemic shock.

The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client? A) Auscultate breath sounds for inspiratory stridor. B) Auscultate breath sounds for crackles. C) Auscultate breath sounds for hyperresonance. D) Auscultate for an absence of breath sounds in the lower lobes.

Answer: B Explanation: Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. Stridor is auscultated with airway obstruction, not pulmonary edema.

The nurse explains the purpose of an infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement indicates that the client understands the instructions? A) "It is a protein that causes my kidneys to conserve fluid." B) "It is a protein that pulls water into my blood vessels." C) "It is a liquid that has electrolytes in it to pull water into my blood vessels." D) "It is a super-concentrated salt solution that helps me conserve body fluid."

Answer: B Explanation: Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Albumin 5% does not act on the kidneys. Albumin 5% is not a concentrated saline solution.

A nurse working in the intensive care unit (ICU) is caring for a client in progressive hemorrhagic shock. When planning care for this client, which does the nurse anticipate? A) A sustained decrease of 10mmHg of the client's mean arterial pressure (MAP) B) A blood loss of 25% C) A change from aerobic to anaerobic metabolism D) A decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space

Answer: C Explanation: In intermediate or progressive hemorrhagic shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35% to 50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.

A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate? A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." C) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure."

Answer: C Explanation: Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of shock. Liver failure is not a type of shock.

A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,500 mL of blood. Based on this data, which type of hemorrhagic shock is the client experiencing? A) Class I B) Class II C) Class III D) Class IV

Answer: C Explanation: This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-2,000mL or 30% to 40% of blood volume.

A client being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the nurse anticipate for this client? A) Stabilization of fluid loss B) Increased cardiac output C) Vasoconstriction and increased blood pressure D) Urinary output of at least 30 mL/hour

Answer: D Explanation: At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading to vasodilation and an increased blood flow through the kidneys. Increased cardiac output occurs with high, not low, doses of dopamine when beta1-adrenergic receptors are stimulated. Vasoconstriction and increased blood pressure occur with high, not low, doses of dopamine when alpha-adrenergic receptors are stimulated. Dopamine does not prevent or stabilize fluid loss.

The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client? A) Deficient Fluid Volume B) Ineffective Coping C) Ineffective Airway Clearance D) Decreased Cardiac Output

Answer: D Explanation: The client sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the client is Decreased Cardiac Output because of low blood volume. There is not enough information to determine whether the client has ineffective airway clearance. The client will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough information to determine whether the client is experiencing ineffective coping.

An older adult client is experiencing hypovolemic shock. Which is the priority intervention for this client? A) Administering analgesics for control of pain B) Assessing the cause of bleeding C) Providing replacement of volume D) Establishing invasive cardiac monitoring

Answer: D Explanation: With aging, there is a decrease in cardiac sympathetic activity. Older clients can have secondary volume depletion because of diuretics or malnutrition, and if prescribed a beta blocker, tachycardia may not occur as an early sign of hypovolemic shock. The older client will require early invasive monitoring in order to avoid excessive or inadequate volume restoration. This should be done early in the treatment phase. Replacement of volume would occur after invasive cardiac monitoring is established. Pain would be a consideration but would not be attended to as a first priority. Assessing the cause of bleeding would also occur after establishing invasive cardiac monitoring.

A client who was stung by a bee is treated with an EpiPen auto-injection. Which assessment finding indicates that the drug is working? 1. Increased blood pressure 2. Constriction of the pupils 3. Increased urinary output 4. Spasm of the bronchus

Correct Answer: 1 Rationale 1: Immediately after injection, blood pressure increases due to stimulation of alpha-1 receptors. Rationale 2: Epinephrine causes pupillary dilation, not constriction. Rationale 3: Epinephrine causes decreased urinary output. Rationale 4: Epinephrine causes bronchodilation due to activation of beta-2 receptors in the bronchi, so the client can breathe freely. Global Rationale: Immediately after injection, blood pressure increases due to stimulation of alpha-1 receptors. Epinephrine causes pupillary dilation, not constriction. Epinephrine causes decreased urinary output. Epinephrine causes bronchodilation due to activation of beta-2 receptors in the bronchi, so the client can breathe freely.

A client is prescribed a high-dose dopamine infusion. The nurse would expect to see an increase in blood pressure because of dopamine's effect on which receptors? 1. Alpha-1 adrenergic receptors 2. Dopaminergic receptors 3. Beta-2 adrenergic receptors 4. Beta-1 adrenergic receptors

Correct Answer: 1 Rationale 1: Stimulation of alpha-1 adrenergic receptors by high doses of dopamine causes vasoconstriction and increased blood pressure. Rationale 2: Dopamine at low doses stimulates dopaminergic receptors, especially in the kidneys, causing vasodilation and increased renal blood flow and urine output. Rationale 3: Dopamine at high doses has no effect on beta-2 adrenergic receptors. Rationale 4: Stimulation of beta-1 adrenergic receptors causes the heart to beat more forcefully, thus increasing cardiac output. Global Rationale: Stimulation of alpha-1 adrenergic receptors by high doses of dopamine causes vasoconstriction and increased blood pressure. Dopamine at low doses stimulates dopaminergic receptors, especially in the kidneys, causing vasodilation and increased renal blood flow and urine output. Dopamine at high doses has no effect on beta-2 adrenergic receptors. Stimulation of beta-1 adrenergic receptors causes the heart to beat more forcefully, thus increasing cardiac output.

The nurse is starting a high-dose dopamine infusion for a client diagnosed with shock. The nurse should monitor the client for which side effect of this drug? 1. Angina 2. Ventricular tachycardia 3. Bronchospasm 4. Urinary retention

Correct Answer: 2 Rationale 1: Dopamine causes angina pain at low doses. Rationale 2: High doses of dopamine stimulate beta-1 receptors, causing the heart to beat more rapidly, hence causing ventricular tachycardia. Rationale 3: Dopamine has no effect on beta receptors in the lungs. Rationale 4: Dopamine does not have an effect on the urinary bladder. Global Rationale: High doses of dopamine stimulate beta-1 receptors, causing the heart to beat more rapidly, hence causing ventricular tachycardia. Dopamine causes angina pain at low doses. Dopamine has no effect on beta receptors in the lungs or the urinary bladder.

A low-dose dopamine infusion is to be started for a client diagnosed with hypovolemic shock. Which assessment finding indicates the drug is having the desired therapeutic effect? 1. Nausea 2. Increased urine output 3. Increased blood pressure 4. Ventricular tachycardia

Correct Answer: 2 Rationale 1: Nausea is a common side effect, not a desired therapeutic effect. Rationale 2: At low doses, dopamine selectively stimulates dopaminergic receptors, especially in the kidneys, causing increased urine output. At higher doses, dopamine stimulates beta-1 adrenergic receptors, causing the heart to beat more forcefully, thus increasing cardiac output. Also, at higher doses, dopamine stimulates alpha-1 adrenergic receptors, causing vasoconstriction and increased blood pressure. Rationale 3: Increased blood pressure is not seen with a low-dose dopamine infusion. Rationale 4: Ventricular tachycardia is not seen with a low-dose dopamine infusion. Global Rationale: At low doses, dopamine selectively stimulates dopaminergic receptors, especially in the kidneys, causing increased urine output. At higher doses, dopamine stimulates beta-1 adrenergic receptors, causing the heart to beat more forcefully, thus increasing cardiac output. Also, at higher doses, dopamine stimulates alpha-1 adrenergic receptors, causing vasoconstriction and increased blood pressure. Nausea is a common side effect, not a desired therapeutic effect. Increased blood pressure and ventricular tachycardia are not seen with a low-dose dopamine infusion.

One of the reasons epinephrine causes an intense fight-or-flight response throughout the body is because it stimulates which receptors? 1. The alpha receptors only 2. All four types of adrenergic receptors 3. The beta-2 receptors only 4. The beta-1 receptors only

Correct Answer: 2 Rationale 1: There are two alpha receptors: alpha-1 and alpha-2. Stimulation of alpha-1 receptors by epinephrine causes pupillary dilatation; stimulation of alpha-2 receptors causes blood pressure to rise and more blood to flow to the peripheral muscles, which is very helpful in the fight-or-flight response. But epinephrine stimulates all four types of receptors. Rationale 2: Epinephrine stimulates all four types of receptors, and hence causes an intense fight-or-flight response, the effects of which are seen all over the body. Rationale 3: Epinephrine stimulates all four types of receptors, not just the beta-2 receptors. Stimulation of beta-2 receptors in the bronchi causes dilatation of the bronchi, which allows easier breathing during a fight-or-flight response. Rationale 4: Epinephrine stimulates all four types of receptors, not just the beta-1 receptors. Beta-1 receptors in the heart cause the heart to beat faster and to provide more blood to the body's tissues. Global Rationale: Epinephrine stimulates all four types of receptors, and hence causes an intense fight-or-flight response, the effects of which are seen all over the body. There are two alpha receptors: alpha-1 and alpha-2. Stimulation of alpha-1 receptors by epinephrine causes pupillary dilatation; stimulation of alpha-2 receptors causes blood pressure to rise and more blood to flow to the peripheral muscles, which is very helpful in the fight-or-flight response. But epinephrine stimulates all four types of receptors.

A client receives epinephrine for anaphylactic shock. The nurse should be aware of which mechanism by which epinephrine acts? 1. Inhibiting reuptake of norepinephrine from the synaptic cleft 2. Indirectly, by promoting release of norepinephrine 3. Directly, by stimulating adrenergic receptors 4. Inhibiting destruction of norepinephrine by enzyme MAO

Correct Answer: 3 Rationale 1: Antidepressant imipramine and cocaine inhibit reuptake of NE from the synaptic cleft back to the presynaptic neuron. Rationale 2: Epinephrine acts directly by stimulating adrenergic receptors. Ephedrine and amphetamine stimulate release of NE from its storage vesicles on the presynaptic neuron. Rationale 3: Epinephrine acts directly by stimulating adrenergic receptors. Rationale 4: Phenelzine (Nardil) is an example of an MAO inhibitor that inhibits destruction of norepinephrine. Global Rationale: Epinephrine acts directly by stimulating adrenergic receptors. Ephedrine and amphetamine stimulate release of NE from its storage vesicles on the presynaptic neuron. Antidepressant imipramine and cocaine inhibit reuptake of NE from the synaptic cleft back to the presynaptic neuron. Phenelzine (Nardil) is an example of an MAO inhibitor that inhibits destruction of norepinephrine.

When planning care, the nurse anticipates that which client will most likely require intravenous fluid replacement? 1. A client with a minor burn to the left arm 2. A client diagnosed with congestive heart failure 3. A client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) 4. A client diagnosed with shock

Correct Answer: 4 Rationale 1: A client diagnosed with a minor burn might not require intravenous fluid replacement. This is not the most likely client to receive fluid replacement. Rationale 2: A client diagnosed with heart failure is likely in a state of fluid volume excess. Rationale 3: A client diagnosed with SIADH is likely in a state of fluid volume excess. Rationale 4: A client in shock will require intravenous fluid replacement secondary to hypotension and fluid shifting. Global Rationale: A client in shock will require intravenous fluid replacement secondary to hypotension and fluid shifting. A client diagnosed with a minor burn might not require intravenous fluid replacement. This is not the most likely client to receive fluid replacement. A client diagnosed with heart failure is likely in a state of fluid volume excess. A client diagnosed with SIADH is likely in a state of fluid volume excess.

Why are adrenergic agonists such as epinephrine given parenterally or by inhalation instead of orally? 1. They are not easily digested in the gastrointestinal tract. 2. They produce toxic by-products in the blood. 3. They are rapidly absorbed by the blood. 4. They are metabolized by the enzyme COMT in the intestinal tract.

Correct Answer: 4 Rationale 1: Adrenergic agonists are not digested in the gastrointestinal tract. Rationale 2: No toxic by-products are produced. Rationale 3: Adrenergic agonists are not rapidly absorbed by the blood. Rationale 4: Epinephrine is metabolized by the enzymes MAO and COMT in the liver and in most tissues; hence, it is not absorbed orally. Global Rationale: Epinephrine is metabolized by the enzymes MAO and COMT in the liver and in most tissues; hence, it is not absorbed orally. Adrenergic agonists are not digested in the gastrointestinal tract. No toxic by-products are produced. Adrenergic agonists are not rapidly absorbed by the blood.

The nurse is getting ready to use an EpiPen auto-injector for a client who was bitten by a wasp. In order for the EpiPen to be fully effective, where will the nurse educate the client to store it? 1. On the counter 2. In the refrigerator 3. At a warm temperature 4. In a dark place

Correct Answer: 4 Rationale 1: An EpiPen should not be exposed to light, so it cannot be kept on counters. Rationale 2: An EpiPen should be kept at room temperature. Refrigeration should be avoided. Rationale 3: An EpiPen is sensitive to heat; it should be kept in a cool, dark place. Rationale 4: An EpiPen is sensitive to light, and so should be kept in a cool, dark place. Global Rationale: An EpiPen is sensitive to light and heat, and so should be kept in a cool, dark place. An EpiPen should be kept at room temperature. Refrigeration should be avoided.