Shock/Sepsis Evolve Questions

A nurse caring for a patient with sepsis completes an intravenous fluid infusion as ordered. Which is a goal for fluid resuscitation when caring for a patient diagnosed with sepsis? 1 Restore tissue perfusion 2 Increase circulating fluid volume 3 Restore blood flow to the myocardium 4 Achieve and maintain a mean arterial pressure of 50 mm Hg

1 Restore tissue perfusion The goal for fluid resuscitation is the restoration of tissue perfusion. Increasing circulating fluid volume is the goal for hypovolemic shock. Restoring blood flow to the myocardium is the goal for cardiogenic shock. Achieving and maintaining a mean arterial pressure of 65 mm Hg is the goal when using vasopressors.

Which manifestation in a patient with systemic inflammatory response syndrome (SIRS) suggests respiratory system dysfunction? 1 Refractory hypoxemia 2 Pulmonary hypotension 3 Increased lung compliance 4 Decreased minute ventilation

1 Refractory hypoxemia In a patient with SIRS, refractory hypoxemia suggests respiratory system dysfunction. Other manifestations of respiratory system dysfunction include pulmonary hypertension, decreased compliance, and increased minute ventilation.

What occurs when the inflammatory response is activated in a patient with systemic inflammatory response syndrome (SIRS)? 1 Release of mediators 2 Decrease in metabolism 3 Damage of the mesothelium 4 Decrease in vascular permeability

1 Release of mediators A release of mediators occurs when the inflammatory response is activated. Other changes that occur include an increase in metabolism or hypermetabolism, direct damage to the endothelium, and an increase in vascular permeability.

A patient admitted to the hospital after a motor vehicle accident (MVA) is in hypovolemic shock. On examination, the nurse finds that the patient is becoming anxious, and the urine output is decreasing. What appropriate action should the nurse perform? 1 Begin crystalloid fluid replacement. 2 Start fluids only if deterioration occurs. 3 Prepare for administering blood products. 4 Wait for the patient to compensate naturally

1 Begin crystalloid fluid replacement. When the volume of blood loss is less than 30 percent, crystalloid fluid replacements are performed to reverse tissue dysfunction. Blood products are administered when the blood volume loss is more than 30 percent. The nurse should not wait for deterioration to occur to start the fluid replacement therapy. This is because the body can typically compensate naturally for a blood volume loss up to 15 percent.

A nurse is reviewing the chart of a 68-year-old patient admitted with pneumonia. The nurse knows that the patient has the potential to develop sepsis based on which risk factors? 1 Age 2 Hearing loss 3 Daily exercise 4 Daily intake of multivitamins

1 Age Sepsis is a constellation of symptoms or syndrome in response to an infection. Advanced age, recent surgery, a history of chronic disease, and immunosuppressive therapy like chemotherapy puts a patient at a greater risk for infection. Hearing loss and daily intake of multivitamins do not increase a patient's risk of infection.

A nurse is caring for a patient diagnosed with septic shock. After an infusion of 30 mL/kg of intravenous fluids, the patient is assessed and has a temperature of 101.4°F (38.6°C), a heart rate of 92 beats/minute, respiration rate of 20 breaths/minute, and a blood pressure of 80/60 mm Hg. Which nursing intervention is a priority for this patient? 1 Redraw lactic acid. 2 Administer a vasopressor. 3 Insert an indwelling urinary catheter. 4 Obtain a 12-lead echocardiograph (ECG).

2 Administer a vasopressor. Patients in septic shock with persistent hypotension who do not respond to fluid resuscitation should be placed on a vasopressor. The physiologic goal is to increase cardiac output and end organ perfusion. The nurse should redraw the lactic acid, obtain a 12-lead ECG, and insert an indwelling urinary catheter while caring for this patient, but these can take place following administration of a vasopressor.

A patient is suspected to have septic shock due to untreated cellulitis in the lower extremity. What findings would the nurse expect to observe when assessing this patient? Select all that apply. 1 Rhonchi 2 Crackles 3 Cyanosis 4 Hyperventilation 5 Decreased urine output

2 Crackles 4 Hyperventilation 5 Decreased urine output In septic shock, the combined effects of the inflammatory mediators result in damage to the endothelium, vasodilation, increased capillary permeability, and neutrophil and platelet aggregation and adhesion to the endothelium. The patient with septic shock may develop crackles due to increased vasodilation and respiratory failure. Initially, the patient may hyperventilate to compensate, resulting in respiratory alkalosis. Symptoms such as decreased urine output are related to renal hypoperfusion. Rhonchi and cyanosis are symptoms of cardiogenic shock.

Which type of shock is associated with hyperglycemia, presence of pulmonary infiltrates in chest x-ray and increased levels of blood urea nitrogen (BUN)? 1 Septic 2 Obstructive 3 Cardiogenic 4 Hypovolemic

3 Cardiogenic Increased blood levels of glucose, nitrogen, and cardiac markers and presence of pulmonary infiltrates are seen in cardiogenic shock. Increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock.

A patient is brought to the emergency department (ED) after multiple bee stings. On assessment, the nurse finds that the patient has edema on the lips and tongue as well as chest pain, dizziness, wheezing, and stridor. What type of shock should the nurse document this as? 1 Septic shock 2 Obstructive shock 3 Neurogenic shock 4 Anaphylactic shock

4 Anaphylactic shock Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is insect venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above. Obstructive shock develops when a physical obstruction to blood flow occurs with decreased cardiac output.

Which form of shock is associated with pruritus? 1 Septic shock 2 Neurogenic shock 3 Obstructive shock 4 Anaphylactic shock

4 Anaphylactic shock Pruritus is a clinical manifestation of anaphylactic shock. Septic shock is initially associated with warm and flushed skin with later changes that include cool and mottled skin. Warm or cool and dry skin is a sign of neurogenic shock. Pale, cool, and clammy skin is a sign of obstructive shock.

A student nurse is caring for a patient diagnosed with sepsis. The student nurse tells the nurse the care plan regarding the administration of antibiotics. Which nursing action requires correction? 1 Provide broad spectrum antibiotics. 2 Administer antibiotics within one hour. 3 Draw blood cultures before the administration of antibiotics. 4 Delay antibiotics administration if the causative organism is unknown.

4 Delay antibiotics administration if the causative organism is unknown. More specific antibiotics may be ordered once the organism has been identified, but administration of antibiotics should not be delayed. Broad spectrum antibiotics are given first. Antibiotics are an important early component of therapy and should be started in the first hour. The nurse should obtain blood cultures before antibiotics are started.

The nurse is mentoring a graduate nurse and is explaining the use of fluids in a patient who is experiencing hypovolemic shock. Which of the following fluids increases osmotic pressure to provide rapid volume expansion? 1 Lactated Ringer's 2 3% sodium chloride 3 Fresh frozen plasma 4 Human serum albumin

4 Human serum albumin Human serum albumin is a colloidal fluid that increases osmotic pressure and will provide rapid volume expansion. Lactated Ringer's and 3% sodium chloride are used for initial volume replacement in shock, but they do not provide rapid volume expansion. Fresh frozen plasma is used to replace blood loss and replace coagulation factors.

A patient in septic shock is receiving fluid resuscitation. How will the nurse most accurately measure urine output? 1 Daily weights 2 Nasogastric tube 3 Strict input and output 4 Indwelling urinary catheter

4 Indwelling urinary catheter The nurse will insert an indwelling urinary catheter to measure adequate urine output. Strict input and output and daily weights are not exact enough for measuring urine output. A nasogastric tube is not related to measuring urine output.

A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? A. Temperature B. Pulse C. Respiration D. Blood pressure

A. Temperature A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.

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

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 does not assess perfusion. Respirations do not assess perfusion.

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

B ~ Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit. The nurse should question the use of the dopamine (Intropin) infusion. All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? A. Localized erythema and edema B. Low-grade fever and mild hypotension C. Low oxygen saturation rate and decreased cognition D. Reduced urinary output and increased respiratory rate

B. Low-grade fever and mild hypotension Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and increased respiratory rate indicate severe sepsis.

How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? A. Urine output 20 to 30 mL/hr for the last 4 hours B. Mean arterial pressure (MAP) 70 mm Hg C. Albumin 3.5 g/dL D. Hemoglobin 7.6 g/dL

B. Mean arterial pressure (MAP) 70 mm Hg Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, which is a desired outcome in shock. Urine output should be 0.5 mL/kg/hr, or greater than 30 mL/hr. Albumin levels reflect nutritional status, which may be poor in shock states due to an increased need for calories. Plasmanate expands blood volume by exerting increasing colloid osmotic pressure in the bloodstream, pulling fluid into the vascular space; this does not improve an abnormal hemoglobin.

Which manifestations of shock are a result of compensatory mechanisms to maintain circulating blood volume? A) Edema and weight gain B) Confusion and lethargy C) Decreased urine output and thirst D) Increased pulse and respiratory rates

C) Decreased urine output and thirst Rationale: Both reduced urine output and thirst are stimulated by a decreasing circulating blood volume. When people can respond to thirst by drinking, the action compensates temporarily by increasing circulating fluid volume. Decreased or absent urine output compensates by preventing a greater fluid loss. The fluid that would have been lost from the body as urine is retained. This is why hourly urine output measurements are such a sensitive indicator for whether shock is improving or progressing. Edema and weight gain are not compensations for circulating blood volume. Confusion and lethargy are responses to circulating blood volume, not compensation to improve it. Increasing pulse and respiratory rates compensate for hypoxia, not for reduced volume.

A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer? a. Normal saline b. Ringer's lactate c. 5% dextrose in water d. 5% dextrose in 0.45% normal saline

B: Ringer's lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as a buffer in the presence of acidosis. The other solutions do not contain any substance that would buffer or correct the client's acidosis.

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

C ~ 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.

Which of the following indicate early sepsis, which has an excellent recovery rate if treated promptly? A. Localized erythema and edema B. Low-grade fever & low white blood cell count C. Low oxygen saturation & decreased cognition D. Reduced urinary output & increased respiratory rate

D. Reduced urinary output & increased respiratory rate

The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which important action related to the administration of this drug does the nurse implement? a. Assess the client's respiratory rate. b. Administer the medication with gravity tubing. c. Protect the medication from light with an opaque bag. d. Monitor for hypertensive crisis.

C: Sodium nitroprusside (Nipride) must be protected from light to prevent degradation of the drug. It should be delivered via pump. This medication does not have any effect on respiratory rate. Hypertension is a sign of milrinone (Primacor) overdose.

A 40-year-old man with a history of IV drug use presents with cellulitis with multiple abscesses of the right upper extremity. His current weight is 70 kg (lean body weight). He rapidly develops worsening respiratory distress and hypotension and ultimately requires intubation and mechanical ventilation. Blood gas analysis shows a pH of 7.23, Paco2 of 58 torr, Pao2 of 60 torr, and an oxygen saturation of 88%. His ventilator settings are assist-control mode with a tidal volume of 420 mL, respiratory rate of 16 breaths/min,positive end-expiratory pressure (PEEP) of 5 cm H2O, and Fio2 of 70%. His plateau pressure on the ventilator is 29 cm H2O. A chest radiograph shows bilateral interstitial infiltrates, and a 2-dimensional echocardiogram demonstrates normal left ventricular function. What ventilator adjustments should be made? (A) Change the ventilator mode to synchronized intermittent mandatory ventilation (B) Increase PEEP (C) Increase respiratory rate to 24 breaths/min (D) Increase tidal volume to 600 mL (E) Leave the ventilator settings unchanged

(B) Increase PEEP. The largest trial of a volume and pressure-limited strategy showed a 9% decrease in all-cause mortality in patients ventilated with tidal volumes of 6 mL/kg of estimated lean body weight as compared with a tidal volume of 12 mL/kg (target plateau pressure, < 30 cm H2O).3 Based on the results of this study, a strategy of using low tidal volume and high PEEP is recommended for mechanical ventilation of acute lung injury/ARDS patients.

A nurse is caring for a patient in the intensive care unit (ICU) admitted with septic shock. The patient has been in the ICU for 36 hours. After 24 hours, which finding increases the patient's risk for developing multiple organ dysfunction syndrome (MODS)? 1 Increased cardiac output 2 Decreased coronary artery perfusion 3 Increased systemic vascular resistance 4 Decreased myocardial oxygen metabolism

1 Increased cardiac output If increased cardiac output persists after 24 hours, the patient in septic shock is at risk of developing hypotension and MODS. Coronary artery perfusion is not primarily altered in septic shock. Decreased, not increased, systemic vascular resistance is associated with an increased risk of MODS. Septic shock does not typically alter myocardial oxygen metabolism.

The nurse reviews the medical record of a patient with pneumonia and notes that the patient has hypotension, hypothermia, leukocytosis, and hypoxemia. What should the nurse infer from these findings? 1 The patient has septic shock. 2 The patient has neurogenic shock. 3 The patient has cardiogenic shock. 4 The patient has hypovolemic shock

1 The patient has septic shock. Septic shock is most commonly found in the patient having gram-negative bacterial infections, such as pneumonia. Because it is characterized by hypotension, hypothermia, leukocytosis, and hypoxemia in patients with infections, the nurse concludes that the patient has septic shock. Neurogenic shock is most commonly seen in the patient who has an injury. Cardiogenic shock is caused by cardiovascular disorders, such as a myocardial infarction and cardiomyopathy. Hypovolemic shock is caused by hemorrhage or trauma.

When planning for home care of a patient who has just recovered from shock, what appropriate measures should the nurse follow? Select all that apply. 1 Admit to rehabilitation center. 2 Allow the patient to resume work. 3 Arrange for transitional care units. 4 Refer to home health care agencies. 5 Assure rapid recovery with self-care.

1 Admit to rehabilitation center. 3 Arrange for transitional care units. 4 Refer to home health care agencies. Patients recovering from shock often require diverse services after discharge. Such services aim at maintaining continuity of care and monitoring the patient for indications of complications. These can include admission to transitional care units, rehabilitation centers, or home health care agencies. The patient may not be able to resume work, because recovery takes time. Self-care is not sufficient, because specialized monitoring and care may be needed.

The nurse is caring for a patient who has hypovolemic shock from hemorrhage. The nurse expects to find which clinical manifestation(s)? Select all that apply. 1 Anxiety 2 Tachycardia 3 Hypotension 4 Hypothermia 5 Lactic acidosis 6 Decreased capillary refill

1 Anxiety 2 Tachycardia 3 Hypotension 6 Decreased capillary refill In a patient with hypovolemic shock due to hemorrhage, assessment findings will be related to intravascular fluid loss that include cool skin, decreased capillary refill, hypotension, orthostatic changes, tachycardia, anxiety, and decreased urine output. Hypothermia is associated with spinal cord injury.

When examining a patient with cardiogenic shock, which signs of peripheral hypoperfusion does the nurse expect? Select all that apply. 1 Cyanosis 2 Cold skin 3 Weak pulse 4 Bradycardia 5 Hypertension

1 Cyanosis 2 Cold skin 3 Weak pulse Cyanosis, cold skin, and a weak pulse are the signs of peripheral hypoperfusion in cardiogenic shock. Bradycardia and hypertension are not seen in cardiogenic shock; instead, tachycardia and low blood pressure are noted.

A nurse is caring for a patient who is in a state of cardiogenic shock caused by myocardial infarction. The nurse uses pulse oximetry to monitor the oxygen saturation levels. Where should the nurse attach the pulse oximetry probe to get an accurate reading? Select all that apply. 1 Ear 2 Toes 3 Nose 4 Fingers 5 Forehead

1 Ear 3 Nose 5 Forehead Pulse oximetry is used to monitor oxygen saturation. The patient in a state of shock has poor peripheral circulation, and a peripheral reading may not be accurate. Therefore the probe should be attached to the ear, nose, or forehead for a reliable measurement. Pulse oximetry readings obtained through the toes and fingers may not be accurate due to compromised peripheral circulation.

When examining a patient in the progressive stage of shock, which factors related to the gastrointestinal (GI) system should the nurse consider? Select all that apply. 1 Increased risk of GI bleeding 2 Increased likelihood of GI ulcers 3 Increased motility and peristalsis 4 Increased ability to absorb nutrients 5 Increased risk of bacterial migration from the GI tract to the bloodstream.

1 Increased risk of GI bleeding 2 Increased likelihood of GI ulcers 5 Increased risk of bacterial migration from the GI tract to the bloodstream. In the progressive stage of shock, the GI system gets affected by prolonged decreased tissue perfusion. As the blood supply to the GI tract is decreased, the normally protective mucosal barrier becomes ischemic. This ischemia predisposes the patient to ulcers and GI bleeding. It also increases the risk of bacterial migration from the GI tract to the blood. The decreased perfusion to the GI tract also results in a decreased ability to absorb nutrients, decreased motility, and slowed peristalsis.

When considering the use of nitroglycerin for treating a patient with shock, what actions should the nurse perform? Select all that apply. 1 Monitor the heart rate. 2 Monitor the blood pressure. 3 Use a glass bottle for infusion. 4 Protect the solution from sunlight. 5 Administer the solution through a central line.

1 Monitor the heart rate. 2 Monitor the blood pressure. 3 Use a glass bottle for infusion. Nitroglycerin is a vasodilator used in the treatment of cardiogenic shock. During medication with nitroglycerin, the patient's heart rate and blood pressure should be continuously monitored in order to prevent any chances of reflex tachycardia. Because plastics tend to adsorb nitroglycerin, glass bottles should be used for infusion to avoid adsorption. The drug can be administered through a peripheral line; a central line is not required. Because it is not photosensitive, the drug does not need to be protected from sunlight.

When examining a patient with septic shock, what symptoms would the nurse expect to find? Select all that apply. 1 Paralytic ileus 2 Pulsus paradoxus 3 Distended jugular vein 4 Decreased urinary output 5 Gastrointestinal (GI) bleeding

1 Paralytic ileus 4 Decreased urinary output 5 Gastrointestinal (GI) bleeding Patients suffering from septic shock may experience decreased tissue perfusion, which may result in a paralytic ileus, GI bleeding, and decreased urinary output. Pulsus paradoxus and jugular vein distension are found in obstructive shock and are mainly the result of compromised hemodynamics.

Which are pathophysiologic effects of septic shock? Select all that apply. 1 Vasodilation 2 Myocardial depression 3 Decreased coagulation 4 Increased ejection fraction 5 Maldistribution of blood flow 6 Increased blood flow in the microcirculation

1 Vasodilation 2 Myocardial depression 5 Maldistribution of blood flow Septic shock has three major pathophysiologic effects: vasodilation, myocardial depression, and maldistribution of blood flow. The release of platelet-activating factors increases coagulation rather than decreasing it, resulting in the formation of microthrombi and decreased blood flow in the microcirculation. Sepsis-induced myocardial dysfunction results in a decreased, not increased, ejection fraction. Because coagulation is increased, blood flow in the microcirculation is decreased, not increased.

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? 1 Insulin infusion 2 Aggressive IV crystalloid fluid resuscitation 3 Intravenous (IV) administration of epinephrine 4 Administration of nitrates and β-adrenergic blockers

2 Aggressive IV crystalloid fluid resuscitation Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock.

A nurse is caring for multiple patients. Which patient does the nurse monitor most closely for possible development of sepsis? 1 A 7-year-old patient with ear pain and history of chronic otitis media 2 An 86-year-old patient with a fever and history of chronic urinary tract infections 3 A 54-year-old patient with a sore throat and no significant previous medical problems 4 A 62-year-old patient with complaints of cough and history of chronic obstructive pulmonary disease (COPD)

2 An 86-year-old patient with a fever and history of chronic urinary tract infections Advanced age, recent surgery, history of chronic disease, and immunosuppressive therapy put a patient at risk of infection. Due to these factors, the 86-year-old patient with a fever and chronic infections has the highest risk for developing sepsis. The 62-year-old patient has risk factors of advanced age and chronic disease, but the lack of fever puts this patient at a lower risk. The 7-year-old patient only exhibits one risk factor, and the 54-year-old patient does not exhibit any risk factors.

A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of which condition? 1 A secondary MI 2 Cardiogenic shock 3 Pulmonary edema 4 Fatal dysrhythmias

2 Cardiogenic shock One of the initial cardinal signs of cardiogenic shock after a myocardial infarction (MI) is a slow, steady drop in blood pressure. Hypotension after an MI may be an indirect sign of a secondary MI or a fatal dysrhythmia. Depending on the origin of pulmonary edema, patients may experience hypotension or hypertension.

Which type of shock is associated with bradycardia? 1 Septic shock 2 Neurogenic shock 3 Anaphylactic shock 4 Hypovolemic shock

2 Neurogenic shock Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. Reduction in preload, capillary refill, and stroke volume are clinical manifestations of hypovolemic shock. Chest pain is seen in anaphylactic shock.

The health care provider prescribes a dose of dobutamine for a patient in cardiogenic shock due to myocardial infarction. What appropriate actions should the nurse perform for safely administering the medication? Select all that apply. 1 Use a glass bottle for infusion. 2 Administer through a central line. 3 Monitor heart rate and blood pressure. 4 Stop infusion if tachydysrhythmias develop. 5 Always administer with sodium bicarbonate.

2 Administer through a central line. 3 Monitor heart rate and blood pressure. 4 Stop infusion if tachydysrhythmias develop. When using dobutamine, the patient's heart rate and blood pressure should be continuously monitored, as it may worsen hypotension, requiring the addition of a vasopressor. The infusion should be stopped if tachydysrhythmias develop. The administration through a central line is recommended, because infiltration leads to tissue sloughing. The drug should not be administered with sodium bicarbonate, because it can get deactivated. Because dobutamine is not adsorbed in plastic containers, it is not necessary to administer the drug in glass bottles.

The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored? Select all that apply. 1 Urine output 2 Cardiac output 3 White blood cells 4 Available hemoglobin 5 Arterial oxygen saturation

2 Cardiac output 4 Available hemoglobin 5 Arterial oxygen saturation Oxygen delivery depends on cardiac output, available hemoglobin, and arterial oxygen saturation (SaO2). The amount of blood that the heart pumps to the body may decide the amount of oxygen delivered to the tissues. Hemoglobin, the protein content in red blood cells, is responsible for carrying oxygen molecules. Low hemoglobin means a low oxygen supply to the tissues. Arterial oxygen saturation indicates the total oxygen carried by the blood in the arteries and implies the level of tissue oxygenation. The urine output and white blood cells are also important parameters to be monitored in a patient who suffers from a shock. However, these do not impact the oxygen delivery directly.

Which medication would the nurse administer to treat renal complications associated with systemic inflammatory response syndrome (SIRS)? 1 Antacids 2 Sucralfate 3 Furosemide 4 Omeprazole

3 Furosemide A SIRS-affected (systemic inflammatory response syndrome) patient is administered a loop diuretic such as furosemide to address renal complications related to hypoperfusion and a decreased glomerular filtration rate. Antacids, sucralfate, and omeprazole act as a stress ulcer prophylaxis for the gastrointestinal system.

When caring for a patient in acute septic shock, what should the nurse anticipate? 1 Administering osmotic or loop diuretics 2 Administering IV diphenhydramine (Benadryl) 3 Infusing large amounts of intravenous (IV) fluids 4 Assisting with insertion of a ventricular assist device (VAD)

3 Infusing large amounts of intravenous (IV) fluids Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. Diphenhydramine may be used for anaphylactic shock, but would not be helpful with septic shock. VADs are useful for cardiogenic shock, not septic shock.

A patient in neurogenic shock is receiving phenylephrine. Which nursing actions are appropriate when caring for this patient? 1 Monitoring for signs of dyspnea and pulmonary edema 2 Monitoring for signs of hypokalemia and hyperglycemia 3 Monitoring for signs of reflex bradycardia and restlessness 4 Monitoring for signs of hypothyroidism and Addison's disease

3 Monitoring for signs of reflex bradycardia and restlessness Phenylephrine is β-adrenergic agonist and may cause bradycardia and restlessness due to central nervous system stimulation. β-adrenergic agonists such as epinephrine cause dyspnea and pulmonary edema. Phenylephrine does not increase the elimination of potassium levels or blood glucose levels. Therefore the patient does not have risk of hypokalemia and hyperglycemia. Phenylephrine does not impair thyroid and adrenal gland functioning. Therefore the nurse will not monitor for the signs of hypothyroidism and Addison's disease.

The nurse is caring for a patient who developed cardiogenic shock. Which medical diagnosis does the nurse suspect? 1 Urosepsis 2 Hemorrhage 3 Myocardial infarction 4 Tension pneumothorax

3 Myocardial infarction

Which types of shock are associated with decreased cerebral perfusion? Select all that apply. 1 Septic shock 2 Neurogenic shock 3 Obstructive shock 4 Cardiogenic shock 5 Anaphylactic shock 6 Hypovolemic shock

3 Obstructive shock 4 Cardiogenic shock 6 Hypovolemic shock Manifestations of cardiogenic shock include decreased cerebral perfusion causing anxiety, confusion and agitation. Decreased cerebral perfusion associated with obstructive shock causes anxiety, confusion, and agitation. Decreased cerebral perfusion associated with hypovolemic shock causes anxiety, confusion and agitation. Septic shock causes mental changes like confusion, agitation, and coma in the late stages. Loss of reflex activity and flaccid paralysis are seen with neurogenic shock. Anxiety, metallic taste, confusion, and impending doom are signs of hypovolemic shock.

hich should the nurse evaluate when performing an assessment of end organ function on a patient who received fluid volume resuscitation for septic shock? Select all that apply. 1 Visual acuity 2 Oral mucosa 3 Urine output 4 Bowel sounds 5 Peripheral pulses 6 Neurologic function

3 Urine output 5 Peripheral pulses 6 Neurologic function The goal for fluid resuscitation is restoration of tissue and end organ perfusion. An assessment of end organ perfusion includes urine output, peripheral pulses, and neurologic function. Visual acuity, oral mucosa, and bowel sounds do not provide relevant data for the nurse to evaluate end organ function.

Which drug causes arterial and venous dilation? 1 Dopamine 2 Vasopressin 3 Phenylephrine 4 Sodium nitroprusside

4 Sodium nitroprusside Sodium nitroprusside acts by dilating both the arteries and veins. It is used in the treatment of cardiogenic shock. Dopamine has inotropic activity. It increases the force of the heartbeat and is used in the treatment of cardiogenic shock. Vasopressin is a vasoconstrictor used mainly in the treatment of septic shock. Phenylephrine acts by constricting the peripheral nerves and is used in the treatment of neurogenic shock.

A patient diagnosed with multiple organ dysfunction syndrome is developing pulmonary edema. The nurse realizes that which factor is the cause of the edema? 1 Tissue hypoxia 2 Unregulated apoptosis 3 Microvascular coagulopathy 4 Uncontrolled systemic inflammation

4 Uncontrolled systemic inflammation During sepsis, early activation of immune cells is followed by down-regulation of their activity, which leads to a state of immune deficiency and increased risk of superinfection. Proinflammatory mediators increase capillary permeability, resulting in edema in organs such as the lungs. This is why the patient is developing pulmonary edema. Evidence of tissue hypoxia will occur in the gastrointestinal tract and the brain first. Unregulated apoptosis is uncontrollable cellular death. Pulmonary edema is not a symptom of unregulated apoptosis. Microvascular coagulopathy will manifest as abnormal clotting factors and microembolism production.

Which findings in a patient with systemic inflammatory response syndrome (SIRS) help the nurse identify cardiovascular system dysfunction? Select all that apply. 1 Decrease in heart rate 2 Decrease in stroke volume 3 Decrease in cardiac output 4 Decrease in blood pressure 5 Decrease in mean arterial pressure 6 Decrease in systemic vascular resistance

4 Decrease in blood pressure 5 Decrease in mean arterial pressure 6 Decrease in systemic vascular resistance A patient with SIRS may have cardiovascular system dysfunction manifested as a decrease in blood pressure, mean arterial pressure, and systemic vascular resistance. Heart rate, stroke volume, and cardiac output tend to increase in such patients.

State the order in which the nurse recalls that the steps of how the systemic inflammatory response syndrome (SIRS) leading to an increase in cardiac output occurs. 1. Decrease in blood pressure and systemic venous return 2. Massive dilation of blood vessels 3. Release of inotropic and chronotropic factors 4. Increase in tissue O2 demands 5. Activation of baroreceptor reflex

4, 2, 1, 5, 3 Systemic inflammatory response syndrome (SIRS) increases tissue oxygen demands, which causes myocardial depression and massive vasodilation. The vasodilation results in a decrease in blood pressure and systemic venous return, which activates the baroreceptor reflex, causing release of inotropic and chronotropic factors. The inotropic factors increase the force of contraction while the chronotropic factors increase the heart rate. The result is an increase in cardiac output.

The client with which problem is at highest risk for hypovolemic shock? A. Esophageal varices B. Kidney failure C. Arthritis and daily acetaminophen use D. Kidney stone

A. Esophageal varices Esophageal varices are caused by portal hypertension; the portal vessels are under high pressure and are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen, not acetaminophen, predispose the client to gastrointestinal bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss or hypovolemia.

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: Pulse 140 beats/min and thready, ABG respiratory acidosis, Blood pressure 60/40 mm Hg, Lactate level 7 mOsm/L, Respirations 40/min and shallow. All of these provider prescriptions are given for the client. Which does the nurse carry out first? A. Notify anesthesia for endotracheal intubation. B. Give Plasmanate 1 unit now. C. Give normal saline solution 250 mL/hr. D. Type and crossmatch for 4 units of packed red blood cells (PRBCs).

A. Notify anesthesia for endotracheal intubation. Establishing an airway is the priority in all emergency situations. Although administering Plasmanate and normal saline, and typing and crossmatching for 4 units of PRBCs are important actions, airway always takes priority.

What is the best understanding of mixed venous oxygen saturation by the nurse? A.An overall picture of oxygen delivery and oxygen consumption B.The amount of oxygen attached to each hemoglobin molecule C.The amount of oxygen perfusion taking place within the myocardium D.The amount of oxygen the lungs are able to mix with the blood

A.An overall picture of oxygen delivery and oxygen consumption Clinical determination of mixed venous oxygen saturation can be measured hemodynamically and provides a picture of the overall oxygen utilization by organs and tissues. Mixed venous oxygen saturation is the percentage of hemoglobin saturation in the central venous circulation, and it provides an assessment of the amount of oxygen used by the tissues.

The nurse needs to obtain a cardiac output measurement from a patient who has just had a pulmonary artery catheter inserted. What are important interventions for ensuring accurate pressure and cardiac output measurements? (Select all that apply.) A.Ensure rapid injection of fluid through the injectate port. B.Zero reference the transducer system at the phlebostatic axis. C.Inflate the pulmonary artery catheter balloon with 5 mL air. D.Use lactated Ringer's solution for the injectate.

A.Ensure rapid injection of fluid through the injectate port. B.Zero reference the transducer system at the phlebostatic axis. To ensure accurate measurement, zero referencing of the transducer system is a priority action. Rapid injection of the appropriate solution will ensure more accurate readings. Inflating the pulmonary artery catheter balloon with 5 mL of air will likely result in rupture of the balloon, as this volume of air is too high. Normal saline or 5% dextrose in water solutions are used for obtaining thermodilution cardiac output measurements

The physician orders continuous cardiac output (CCO) monitoring for a patient admitted in cardiogenic shock. Which statement(s) best describes advantages associated with the continuous monitoring of cardiac output? (Select all that apply.) A.No extra fluid is administered to the patient. B.The device senses CCO in hypothermic patients. C.Data are continuously available for trending. D.There is no need to change the computation constant. E.The device detects acute changes in cardiac output.

A.No extra fluid is administered to the patient. C.Data are continuously available for trending. D.There is no need to change the computation constant. Continuous cardiac output monitoring offers several advantages over the thermodilution method of monitoring, including less fluid administration to the patient, data continuously available for trending and not having to change the computation constant. The device does not accurately detect Continuous cardiac output values in patients whose body temperatures are greater than 40° C to 43°C because the thermal filament heats to a maximum of 44°C. The device does not detect acute changes in cardiac output because measurements provide an average of cardiac output over time

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

ANS: A 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

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.

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

ANS: B Since 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 also will be reported, but does not indicate deterioration of the patient's status.

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

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.

15 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? (SATA) a. Administer acetaminophen (Tylenol). b. Document the patient's response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the physician. f. Stop the transfusion.

B, 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. 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.

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? A. Client receiving a blood transfusion B. Client with severe ascites C. Client with myocardial infarction D. Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

B. Client with severe ascites Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

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

D ~ 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.

Which of the following is an indication for using corticosteroids in septic shock? (A) Acute respiratory distress syndrome (ARDS) (B) Necrotizing pneumonia (C) Peritonitis (D) Sepsis responding well to fluid resuscitation (E) Vasopressor-dependent septic shock

E) Vasopressor-dependent septic shock. An inappropriate cortisol response is not uncommon in patients with septic shock. Low-dose IV corticosteroids (hydrocortisone 200-300 mg/day) are recommended

Nursing assessment of a client receiving serum albumin for treatment of shock should include: a.) Assessing lung sounds. b.) Monitoring glucose. c.) Monitoring the potassium level. d.) Monitoring hemoglobin and hematocrit.

a.) Assessing lung sounds. Rationale: Colloids pull fluid into vascular space. Circulatory overload could occur. The nurse should assess the client for symptoms of heart failure.