Shock, SIRS, MODS, DIC
Cardiogenic Shock
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Hypovolemic Shock
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SIRS
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Anaphylactic Shock
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Medications
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DIC
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MODS
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Neurogenic Shock
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Septic Shock
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A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient? Select all that apply. a. Administer epinephrine IM intramuscularly. b. Prepare to administer antithrombolytic agents as prescribed. c. Apply oxygen via face mask as prescribed. d. Provide diphenhydramine 25 mg intravenous. e. Administer vasopressin.
a. Administer epinephrine IM intramuscularly. c. Apply oxygen via face mask as prescribed. d. Provide diphenhydramine 25 mg intravenous. Epinephrine produces bronchodilation, improving the respiratory status. The route of administration is initially intramuscular. Supplemental oxygen is used in the treatment of anaphylactic shock. Hydrogen ion blockers such as diphenhydramine may be administered to block the histamine effects.
The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone
a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L.
A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss
a. Bacterial toxins lead to vasodilation.
A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply.) a. Blood cultures 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. Complete blood count (CBC) with differential
a. Blood cultures 2 b. Wound cultures c. Urine cultures d. Sputum cultures
A patient is receiving phenylephrine 50 mcg/min as treatment for shock. Which assessment finding indicates this medication is effective? a. Blood pressure 110/68 mm Hg b. Heart rate 110 c. Respiratory rate 12 and regular d. Decreased peripheral pulses
a. Blood pressure 110/68 mm Hg The expected effect of this medication is an increase in blood pressure. Phenylephrine is a vasopressor/vasoconstrictor.
Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? a. CVP = 8 mm Hg b. MAP = 45 mm Hg c. Urinary output of 0.1 mL/kg/hr d. Hct = 54%
a. CVP = 8 mm Hg A CVP reading of 8 mm Hg is within normal range and rehydration has been restored.
A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/s/cm-5
a. Cardiac output (CO) of 8 L/min Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.
The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock? a. Cardiogenic b. Hypovolemic c. Distributive d. Obstructive
a. Cardiogenic Anterior MI
The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient? Select all that apply. a. Dopamine b. Norepinephrine c. Dobutamine d. Epinephrine e. Phenylephrine
a. Dopamine b. Norepinephrine c. Dobutamine e. Phenylephrine
A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Select all that apply. a. Elevated pulmonary arterial wedge pressure b. Elevated central venous pressure c. Elevated systemic vascular resistance index d. Elevated mean arterial pressure e. Elevated stroke volume
a. Elevated pulmonary arterial wedge pressure b. Elevated central venous pressure c. Elevated systemic vascular resistance index
The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Select all that apply. a. Hypotension b. Bradycardia c. Warm dry skin d. Abdominal cramps e. Palpitations
a. Hypotension b. Bradycardia c. Warm dry skin
A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock? a. Hypovolemic b. Cardiogenic c. Neurogenic d. Distributive
a. Hypovolemic
The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system
a. Inability of the heart to pump blood forward
A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag
a. Inserting a large-diameter peripheral intravenous catheter
A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? a. Jugular vein distention b. Dry mucous membranes c. Poor skin turgor d. Thirst
a. Jugular vein distention
A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation c. Injury to the hypothalamus d. Focal injury to cerebral hemispheres
a. Loss of sympathetic nervous system innervation Neurogenic shock can be caused by anything that disrupts the sympathetic nervous system (SNS). The problem can occur as the result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain. The most common cause is spinal cord injury (SCI).
The client is admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? a. Oozing blood from the IV catheter site b. Sudden onset of chest pain and frothy sputum c. Foul smelling, concentrated urine d. A reddened, inflamed central line catheter site
a. Oozing blood from the IV catheter site
A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility
a. Peripheral vasodilation
A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? Select all that apply. a. Recent bee sting b. Ingestion of drugs c. History of latex allergy d. Recent diagnostic imaging tests e. Recent myocardial infarction
a. Recent bee sting b. Ingestion of drugs c. History of latex allergy d. Recent diagnostic imaging tests
A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: a. Reduced cardiac output b. Increased stroke volume c. Reduced blood volume d. Blood flow blocked in the pulmonary circulation
a. Reduced cardiac output In cardiogenic shock, cardiac output is reduced, leading to poor tissue perfusion.
Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? a. Reduced wheezing b. Heart rate 55 and regular c. Blood pressure 98/50 mm Hg d. Respiratory rate 28
a. Reduced wheezing An expected action for epinephrine is bronchodilation as evidenced by less wheezing.
The client in shock is prescribed an infusion of lactated Ringer's solution. The nurse recognizes that the function of this fluid in the treatment of shock is to: a. Replace fluid, and promote urine output. b. Draw water into cells. c. Draw water from cells to blood vessels. d. Maintain vascular volume.
a. Replace fluid, and promote urine output.
An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. Sepsis b. Delirium c. Adult respiratory distress syndrome d. Acute kidney injury
a. Sepsis Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the presence of an existing infection.
During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? Select all that apply. a. Systolic blood pressure 82 mm Hg b. Capillary refill 10 seconds c. Crackles bilateral lung bases d. Heart rate 55 and regular e. Warm dry skin
a. Systolic blood pressure 82 mm Hg b. Capillary refill 10 seconds c. Crackles bilateral lung bases Tachycardia, not bradycardia Cool, pale, moist skin
A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a. The cardiac output is elevated. b. The central venous pressure (CVP) is increased. c. The systemic vascular resistance (SVR) is high. d. The PAWP is high.
a. The cardiac output is elevated. In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.
A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate: a. administration of furosemide (Lasix) IV. b. titration of an epinephrine (Adrenalin) drip. c. administration of a normal saline bolus. d. assisting with endotracheal intubation.
a. administration of furosemide (Lasix) IV. The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase myocardial oxygen demand and might extend the MI. The PAWP is already elevated, so normal saline boluses would be contraindicated. There is no indication that the patient requires endotracheal intubation.
Which lab result would the nurse expect in the client diagnosed with DIC? a. A decreased prothrombin time (PT) b. A low fibrinogen level c. An increased platelet count d. An increased white blood cell count
b. A low fibrinogen level Fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.
The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep mean arterial blood pressure greater than 65 mm Hg. d. Administer crystalloid fluids.
b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.
A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? a. Hypovolemic b. Cardiogenic c. Anaphylactic d. Obstructive
b. Cardiogenic In cardiogenic shock, there is a low cardiac output, hypotension, and pulmonary edema (crackles).
A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness c. Bounding radial and pedal pulses d. Widening pulse pressure
b. Decreased level of consciousness Flat jugular veins, thready pulses, narrowed pulse pressure
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume
b. Excessive thrombosis and fibrinolysis Disseminated intravascular coagulation (DIC) results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways.
A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs
b. Finding and eradicating the cause of infection
A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure e. Decreased pulmonary artery occlusion pressure
b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min; cool, pale, moist skin; weak, thready pulse; and increased right atrial pressure and pulmonary artery occlusion pressure.
Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: a. Monitoring for fluid overload. b. Monitoring for cardiac dysrhythmias. c. Monitoring respiratory status. d. Monitoring for hypotension.
b. Monitoring for cardiac dysrhythmias. Dobutamine is beneficial in cases where shock is caused by heart failure. The drug increases contractility, and has the potential to cause dysrhythmias.
The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure
b. Obtain a serum lactate level
The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS? a. Patient experiences hypometabolism. b. Patient experiences hypermetabolism. c. Patient experiences anorexia. d. Patient has gut dysfunction.
b. Patient experiences hypermetabolism.
A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.
b. Primary MODS is the result of a direct organ injury.
What will the nurse identify as symptoms of hypovolemic shock in a patient? Select all that apply. a. Temperature of 97.6°F (36.4°C) b. Restlessness c. Decrease in blood pressure of 20 mm Hg when the patient sits up d. Capillary refill time greater than 3 seconds e. Sinus bradycardia of 55 beats per minute
b. Restlessness c. Decrease in blood pressure of 20 mm Hg when the patient sits up d. Capillary refill time greater than 3 seconds
A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor
b. Spinal cord injury
To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are a. stool guaiac and bowel sounds. b. lung sounds and oxygenation status. c. serum creatinine and urinary output. d. serum bilirubin levels and skin color.
b. lung sounds and oxygenation status. The respiratory system is usually the FIRST system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.
Which collaborative treatment would the nurse anticipate in the client diagnosed with DIC? a. Administer oral anticoagulants b. Prepare for plasmapheresis c. Administer fresh frozen plasma d. Calculate the intake and output
c. Administer fresh frozen plasma
The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: a. Decreased cardiac output b. Severe constipation, causing watery diarrhea c. Ascites d. Syndrome of inappropriate ADH (SIADH)
c. Ascites Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock.
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels
c. Decreased platelet counts Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of disseminated intravascular coagulation (DIC). DIC does not affect serum glucose levels.
A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine
c. Dobutamine Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice.
A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes b. Lack of food ingestion leads to intestinal hypomotility c. Hypoperfusion results in loss of gut barrier function d. Low cardiac output causes decreased hydrochloric acid secretion
c. Hypoperfusion results in loss of gut barrier function
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a. Antibiotics to treat the underlying infection. b. Corticosteroids to reduce inflammation. c. IV fluids to increase intravascular volume. d. Vasopressors to increase blood pressure.
c. IV fluids to increase intravascular volume. Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage.
A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intraaortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)
c. Insertion of an intraaortic balloon pump (IABP)
A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response
c. Repeat exposure to an antigen in the presence of preformed IgE antibodies
The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS)
c. Sepsis
Multiple organ dysfunction syndrome (MODS) develops in severe sepsis as a result of systemic inflammatory response syndrome (SIRS), disseminated intravascular coagulation and damage to the endothelium. Which of the following statements best describes the management of MODS? a. The use of proton pump inhibitors and H2 agents to increase the pH of the stomach inhibit the development of stress ulcers, an ileus and malabsorption issues. b. Maintaining ventilator settings that ensure a tidal volume of at least 6 mL/kg of body weight will keep the lungs from being injured by endothelial damage. c. There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s). d. Much of the organ damage that occurs with MODS in the setting of severe sepsis is associated with pre-existing conditions.
c. There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s).
The client with which condition is at the greatest risk of developing acute disseminated intravascular coagulation? a. Aortic aneurysm b. Gunshot wound to the distal arm c. Third-degree burns and septic shock d. Bacterial pneumonia treated with antibiotics
c. Third-degree burns and septic shock
The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury? a. Arachidonic acid metabolite b. Platelet-activating factor c. Tumor necrosis factor d. Interleukin
c. Tumor necrosis factor
A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a. cool, clammy skin. b. shortness of breath. c. heart rate of 48 beats/min d. BP of 82/40 mm Hg.
c. heart rate of 48 beats/min
A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. nitroglycerine (Tridil). b. dobutamine (Dobutrex). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
c. norepinephrine (Levophed).
A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b. stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.
c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.
Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? a. A 35 year old pregnant client with placenta previa b. A 42 year old client with a pulmonary embolus c. A 60 year old client receiving hemodialyasis 3 days a week d. A 78 year old client with septicemia
d. A 78 year old client with septicemia DIC is a clinical syndrome that develops as a complication of a wide variety of other disorders, with sepsis being the most common cause of DIC
A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time? a. Limit patient movement. b. Prepare to administer crystalloids. c. Administer phenylephrine as prescribed. d. Administer atropine as prescribed.
d. Administer atropine as prescribed.
When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize? a. Intensity of peripheral pulses and body temperature. b. Peripheral pulses and heart rate (HR). c. Metabolic alkalosis and oxygen saturation. d. Cardiac output (CO) and blood pressure (BP).
d. Cardiac output (CO) and blood pressure (BP).
The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index
d. Decreased cardiac index
A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine
d. Epinephrine
The nurse concludes that both clotting and bleeding occur during disseminated intravascular coagulation (DIC) due to which process? a. Tissue damage from bleeding uses up clotting factors quicker than they can be replaced. b. Activation of intrinsic pathways results in release of excess clotting factors. c. Only clotting occurs during DIC, as clotting factors are replaced and available to prevent excess bleeding. d. Excess release of thrombin uses up clotting factors quicker than they can be replaced.
d. Excess release of thrombin uses up clotting factors quicker than they can be replaced.
The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? a. Slow the IV infusion rate b. Administer dopamine c. No interventions are needed at this time d. Increase the IV infusion rate
d. Increase the IV infusion rate
The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with DIC. Which would be an appropriate goal? a. The client's clot formations will resolve in two days b. The saturation of the client's dressings will be documented c. The client will use lemon-glycerin swabs for oral care d. The client's urine output will be > 30 mL per hour
d. The client's urine output will be > 30 mL per hour The problem is addressing the potential for hemorrhage, and a urine output of greater than 30 mL/hr indicates the kidneys are being adequately perfused and the body is not in shock.
