230 Med Surg Final 2/4
Which drug is prescribed particularly in patients with septic shock? Milrinone Hydrocortisone Sodium nitroprusside Phenylephrine HCl
Hydrocortisone (Severe sepsis may result in adrenal insufficiency. Therefore, low doses of corticosteroids are prescribed in the form of IV hydrocortisone during the treatment to prevent adrenal insufficiency. In hypovolemic shock, adrenal insufficiency may not occur. Milrinone helps in improving contractility, and its administration is not limited to septic shock. Sodium nitroprusside improves myocardial perfusion and is not limited to septic shock. Phenylephrine HCl helps in improving mean arterial pressure and therefore can be prescribed in both septic and hypovolemic patients.)
Which medications are often used to provide adrenal support for the patient with severe sepsis? Select all that apply. Penicillin Levofloxacin Hydrocortisone Fludrocortisone Vancomycin
Hydrocortisone Fludrocortisone (During severe sepsis, the body's immune response can become self-destructive if not controlled. Drugs that provide adrenal support during severe sepsis are IV hydrocortisone and oral fludrocortisone. IV penicillin, levofloxacin, and vancomycin are antibiotics that help to kill the bacteria causing the sepsis.)
What is the primary pacemaker of the heart? Bundle of His Purkinje fibers Sinoatrial (SA) node Atrioventricular (AV) node
Sinoatrial (SA) node (The sinoatrial (SA) node is the primary pacemaker of the heart; it generates the heart's electrical impulses. The bundle of His and Purkinje fibers are responsible for rapid conduction of impulses through the ventricles; they are not the primary pacemakers of the heart. The atrioventricular (AV) node causes impulses to slow down or to be delayed before proceeding to the ventricles.)
Determine the heart rate for a patient with 12 QRS complexes in the 6-second strip. 12 100 110 120
120 (The answer is determined by multiplying 12 complexes by 10 to reach the heart rate per 60 seconds (1 minute): 120 bpm.)
A patient weighing 176 lb is to receive a dopamine (Intropin) continuous intravenous (IV) infusion at 5 mcg/kg/min. The solution strength available is dopamine 400 mg in 500 mL D5W. The nurse will infuse the medication at which rate? 20 mL/hr 30 mL/hr 40 mL/hr 50 mL/hr
30 mL/hr (The patient's weight of 176 lb is converted to kilograms by dividing 176 by 2.2, which equals 80 kg. 5 mcg/kg/min multiplied by 80 kg equals 400 mcg, or 0.4 mg/min. Dividing 0.4 mg/min by 400 mg/500 mL = 0.5 mL/min, which when multiplied by 60 minutes = 30 mL/hour.)
Which problem places a person at highest risk for septic shock? Kidney failure Cirrhosis Lung cancer 40% burn injury
40% burn injury (A client with 40% burn injury is at highest risk for septic shock and possible death. The skin forms the first barrier to prevent entry of organisms into the body.Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client. The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin.)
Which waveform indicates proper function of the sinoatrial (SA) node? The QRS complex is present. The PR interval is 0.24 second. A P wave precedes every QRS complex. The ST segment is elevated.
A P wave precedes every QRS complex. (A P wave is generated by the SA node and represents atrial depolarization and needs to be followed by a QRS complex. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead.The QRS complex represents ventricular depolarization. The PR interval represents time required for atrial depolarization and for the impulse delay in the atrioventricular node and travel time to the Purkinje fibers. Normal PR level is up to 0.20 seconds. Elevation of the ST segment indicates myocardial injury.)
When assessing for cardiovascular effects of an adrenergic (sympathomimetic) drug, the nurse understands that these drugs produce which effect on the heart? A positive inotropic, positive chronotropic, and positive dromotropic effect A positive inotropic, negative chronotropic, and negative dromotropic effect A negative inotropic, positive chronotropic, and positive dromotropic effect A negative inotropic, negative chronotropic, and negative dromotropic effect
A positive inotropic, positive chronotropic, and positive dromotropic effect (Adrenergic stimulation of the beta₁-adrenergic receptors on the myocardium and in the conduction system of the heart results in an increased heart rate (positive chronotropic effect), increased contractility (positive inotropic effect), and increased conductivity (positive dromotropic effect).)
What metabolic changes occur as a result of tissue ischemia during the compensatory stage of hypovolemic shock? Select all that apply. Acidosis Alkalosis Hypokalemia Hyperkalemia Vasodilatation
Acidosis Hyperkalemia (In the compensatory (nonprogressive) stage of shock, tissue hypoxia leads to acidosis because of changes in anaerobic metabolism. Hyperkalemia occurs as well from the changes in metabolism. The patient is acidotic, not alkalotic. Hypovolemic shock is associated with vasoconstriction, not vasodilation.)
A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. Ask family members to stay with the client. Call the health care provider. Increase IV and oxygen rates. Remain with the client. Reassure the client that everything is being done for him or her.
Ask family members to stay with the client. Remain with the client. Reassure the client that everything is being done for him or her. (To support the psychosocial integrity of a client in early shock, the nurse would have a familiar person nearby to comfort the client. The nurse would also remain with the client and offer genuine support to reassure the client that everything is being done for her.The health care provider would be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.)
What specialized function of myocardial cells gives them a pacing function? Excitability Contractility Conductivity Automaticity
Automaticity (Automaticity, also known as pacing function, is the ability of the myocardial cells to generate an impulse. The cells that generate the impulses are called primary pacemaker cells; they are mainly located in the sinoatrial node. Excitability is the ability of non-pacemaker heart cells to respond to an electrical impulse which begins in pacemaker cells. Contractility is the mechanical activity of the heart. Conductivity is the ability to end impulses from cell membrane to cell membrane.)
After norepinephrine is administered to a patient with hypovolemic shock, which assessment factor is used to verify the effectiveness of the treatment? Blood pressure Urinary output Level of consciousness Blood glucose
Blood pressure (Norepinephrine is a vasoconstrictor drug used in hypovolemic shock to increase perfusion and oxygenation. These drugs constrict the blood vessels and increase venous return. Urine production will not increase until blood pressure rises and perfuses the kidneys. Norepinephrine does not have any effect on a patient's level of consciousness or blood glucose levels.)
A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? Hourly urine output 10 to 12 mL/hr Blood pressure 90/60 mm Hg and mean arterial pressure 70 mmHg Blood glucose 245 mg/dL (13.6 mmol/L) Serum creatinine 3.6 mg/dL (318 mcmol/L)
Blood pressure 90/60 mm Hg and mean arterial pressure 70 mmHg (A positive outcome of a Dopamine infusion started on a client with septic shock is a blood pressure of 90/60 mm Hg and a mean arterial pressure of 70 mm Hg. Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and are a negative consequence of shock, not a positive response. Although a blood glucose of 245 mg/dL (13.6 mmol/L) is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.)
A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95°F (35°C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? Broad-spectrum antibiotics Blood transfusion Cooling baths NPO status
Broad-spectrum antibiotics (From the sepsis resuscitation bundle the nurse initiates broad-spectrum antibiotics within 1 hour of establishing diagnosis.A blood transfusion is indicated for low red blood cell count or low hemoglobin and hematocrit. Transfusion is not part of the sepsis resuscitation bundle. Cooling baths neither are indicated because the client is hypothermic nor are this part of the sepsis resuscitation bundle. NPO status neither is indicated for this client nor is it part of the sepsis resuscitation bundle.)
A client with hypovolemic shock has these vital signs: temperature 97.9°F (36.6°C) pulse 122 beats/min blood pressure 86/48 mmHg respirations 24 breaths/min urine output 20 mL for last 2 hours skin cool and clammy. Which prescription order for this client does the nurse question? Dopamine (Intropin) 12 mcg/kg/min Dobutamine (Dobutrex) 5 mcg/kg/min Plasmanate 1 unit Bumetanide (Bumex) 1 mg IV
Bumetanide (Bumex) 1 mg IV (The prescription order the nurse questions is Bumetanide (Bumex0 1 mg IV). A diuretic such as bumetanide will decrease blood volume in a client who is already hypovolemic. This order must be questioned because this is not an appropriate action to expand the client's blood volume.The orders other than Bumetanide are appropriate for improving blood pressure in shock and do not need to be questioned.)
Ch. 18: Adrenergic Drugs
Ch. 18: Adrenergic Drugs
Ch. 34: Care of Patients with Dysrhythmias
Ch. 34: Care of Patients with Dysrhythmias
Ch. 37: Care of Patients with Shock
Ch. 37: Care of Patients with Shock
When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? Obtain IV access and hang prescribed fluid infusions. Apply the automatic blood pressure cuff. Assess level of consciousness and pupil reaction to light. Check the airway and respiratory status.
Check the airway and respiratory status. (The nurse's first action when caring for an obtunded client admitted with shock is to check the client's airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority.The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.)
The nurse is caring for a patient who requires a 12-lead electrocardiogram (ECG). Which interventions should the nurse perform to ensure the best signal transmission? Select all that apply. Clean and dry skin Avoid areas with scar tissue Clip hair in the area being used Use non-scented lotions on chest Ensure gel on electrodes is not moist
Clean and dry skin Avoid areas with scar tissue Clip hair in the area being used (Prior to an electrocardiogram (ECG), the skin should be clean and dry. Areas with scar tissue should not have electrodes placed there. The hair around the site of the electrode application should be clipped prior to ECG. Lotions should not be used in that area before the ECG, and the gel should be moist on the electrodes for best conduction.)
Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? Client receiving a blood transfusion Client with severe ascites Client with myocardial infarction Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion
Client with severe ascites (A client with severe ascites best demonstrates the problem with the highest risk for hypovolemic shock. Fluid shifts from vascular to intraabdominal may cause decreased circulating blood volume and poor tissue perfusion.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, but 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 unlicensed assistive personnel (UAP) is concerned about a postoperative client with: blood pressure (BP) of 90/60 mmHg heart rate of 80 beats/min respirations of 22 breaths/min. What does the supervising nurse do? Compare these vital signs with the last several readings. Request that the surgeon see the client. Increase the rate of intravenous fluids. Reassess vital signs using different equipment.
Compare these vital signs with the last several readings. (The supervising nurse will take the vital sign trends into consideration. A BP of 90/60 mmHg may be normal for this client.Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment must be used when vital signs are taken postoperatively.)
The nurse is caring for a patient on a telemetry unit who has: a regular heart rhythm and rate of 60 beats/min a P wave precedes each QRS complex PR interval is 0.20 second. Additional vital signs are as follows: blood pressure 118/68 mm Hg respiratory rate 16 breaths/min temperature 98.8°F (37°C). All of these medications are available on the medication record. What action does the nurse take? Administer atropine. Administer digoxin. Administer clonidine. Continue to monitor.
Continue to monitor. (The nurse needs to take no action other than to continue monitoring because the patient is displaying a normal sinus rhythm and normal vital signs.Atropine is used in emergency treatment of symptomatic bradycardia. This patient has a normal sinus rhythm. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.)
Which property of the heart is considered its mechanical activity? Excitability Conductivity Automaticity Contractility
Contractility (Contractility is the ability of the myocardial cells of atria and ventricles to shorten their fiber length in response to electrical stimulation. This causes sufficient pressure to push blood forward through the heart. Therefore, contractility is known as the mechanical property of the heart. Excitability, conductivity, and automaticity are not the mechanical properties of the heart.)
After teaching a patient's family members about hypovolemic shock, the nurse asks them about the early signs and symptoms that appear in the nonprogressive stage. What symptom identified by a family member requires further teaching? Cyanosis Restlessness Increased respiratory rate Decreased urine output
Cyanosis (Cyanosis appears later, in the progressive stage of hypovolemic shock. Earlier signs and symptoms of the nonprogressive stage include restlessness, increased respiratory rate, and decreased urine output.)
What are the actions of renin in the maintenance of blood pressure? Select all that apply. Decrease urine output Decrease sodium reabsorption Constrict peripheral blood vessels Stimulate cardiac pump activity Increase blood potassium levels
Decrease urine output Constrict peripheral blood vessels (Renin is produced in the body as a response to low blood pressure. This enzyme helps in maintaining blood pressure by decreasing urine output and constricting peripheral blood vessels. Renin also increases sodium reabsorption in the kidney which causes further retention of water. Renin does not directly affect cardiac function or potassium levels.)
Which laboratory result is seen in late sepsis? Decreased serum lactate Decreased segmented neutrophil count Increased numbers of monocytes Increased platelet count
Decreased segmented neutrophil count (A decreased segmented neutrophil count is indicative of late sepsis. The segmented neutrophils (segs) may no longer be elevated because prolonged sepsis may have exceeded the bone marrow's ability to keep producing and releasing new mature neutrophils.Serum lactate is increased, not decreased, in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis. Late in sepsis, platelets may decrease due to consumptive coagulopathy.)
Which is associated with hypovolemic shock? Dehydration Pulmonary embolus Myocardial infarction Chemical-induced sepsis
Dehydration (Dehydration is a symptom of hypovolemic shock. This is because in hypovolemic shock, there is a decrease in the total body fluids. Pulmonary embolus is a result of direct pump failure, which indicates cardiogenic shock. Myocardial infarction occurs due to decreased cardiac function, which causes obstructive shock. Chemical-induced sepsis is caused by fluid shift from the central vascular space. This results in distributive shock.)
Which is a risk factor for distributive shock? Use of ginkgo biloba Diminished thirst reflex Diminished immune response Presence of cardiomyopathies
Diminished immune response (The risk factor for distributive shock is diminished immunity response. Use of ginkgo biloba can result in hypovolemic shock. Diminished thirst reflex is a risk factor for hypovolemic shock. Presence of cardiomyopathies is a risk factor for cardiogenic shock.)
Which physiological change is related to septic shock? High blood pressure Elevated WBC count Increased urinary output Decreased respiratory rate
Elevated WBC count (Septic shock is always due to an underlying infection. An elevated WBC count is associated with septic shock. There is a progressive organ dysfunction resulting in low blood pressure, and decreased urinary output. The respiratory rate is increased to compensate for hypoxia in the tissues.)
The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? Administer the antibiotic immediately. Ensure that blood cultures were drawn. Obtain signature for informed consent. Take the client's vital signs.
Ensure that blood cultures were drawn. (The nurse's first action when planning to administer an antibiotic to a newly admitted patent in septic shock is to ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken.A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours, because timing is essential.)
The client with which problem is at highest risk for hypovolemic shock? Esophageal varices Kidney failure Arthritis and daily acetaminophen use Kidney stone
Esophageal varices (The client with esophageal varices is at highest risk for hypovolemic shock. Esophageal varices are caused by portal hypertension where the portal vessels are under high pressure. With this high pressure, the portal vessels 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. Arthritis and daily acetaminophen use do not cause GI bleeding and hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen may predispose the client to gastrointestinal (GI) bleeding and hypovolemia. Although a kidney stone may cause hematuria, massive blood loss or hypovolemia generally does not occur.)
The health care provider has prescribed dopamine (Intropin) to treat the patient's hypovolemic shock secondary to severe blood loss. For the medication to be effective, the health care provider must also prescribe which treatment? Fluid replacement Temporary pacing Beta-stimulating drugs Induced hypothermia
Fluid replacement (Dopamine increases blood pressure secondary to vasoconstriction, which has a limited effect if there is not enough volume within the circulatory system.)
Which are risk factors for hypovolemic shock? Select all that apply. Hemophilia Malnutrition Diuretic therapy Spinal cord injury Myocardial infarction
Hemophilia Malnutrition Diuretic therapy (Specific risk factors for hypovolemic shock include hemophilia, malnutrition, and diuretic therapy. Hypovolemia can be caused by impaired clotting in patients with hemophilia and malnourishment. Excessive diuresis due to diuretic therapy can also cause reduction in blood volume. Patients with spinal cord injury have distributive shock in which the total blood volume is not reduced but fluid shifts from the central vascular space. In patients with myocardial infarction, cardiac function is impaired which causes cardiogenic shock.)
Which physiological change in a patient with septic shock indicates a poor prognosis? Rapid respiratory rate Low oxygen saturation Change in patient's cognition Hypodynamic cardiac function
Hypodynamic cardiac function (Sepsis often progresses into irreversible septic shock and is associated with a poor prognosis. Hypodynamic cardiac function in septic shock indicates deterioration. A rapid respiratory rate, low oxygen saturation, and a change in the patient's cognition are present during this stage of severe sepsis. These can be reversed with appropriate and timely treatment.)
Which type of shock may result if hemorrhage in a patient is not treated in time? Distributive shock Obstructive shock Cardiogenic shock Hypovolemic shock
Hypovolemic shock (Hemorrhage can result in hypovolemic shock, which occurs when the mean arterial pressure decreases due to loss of blood from the vascular space resulting in inadequate total body perfusion and oxygenation. A loss of blood does result in distributive, obstructive, and cardiogenic shock; therefore, these are not associated with hemorrhage.)
Which shock results in a decrease of total body fluids? Cardiogenic shock Distributive shock Obstructive shock Hypovolemic shock
Hypovolemic shock (Hypovolemic shock results in a decrease of total body fluids. Cardiogenic shock is indicated by direct pump failure. In distributive shock, the fluid shifts from the central vascular space. In obstructive shock, cardiac function is decreased due to indirect pump failure.)
Which clinical manifestation may be evident in the initial stage of hypovolemic shock? Decrease in urine output Decrease in cardiac output Increase in heart and respiratory rate A 2-5% decrease in oxygen saturation
Increase in heart and respiratory rate (The initial stage of hypovolemia can be detected only by an increase in heart and respiratory rates. Reduction in urine output is a manifestation of the nonprogressive stage. Antidiuretic hormone increases water reabsorption in the kidneys which results in decreased urine output. In the initial stage of hypovolemia, the compensatory mechanisms are efficient in maintaining cardiac output, so there is no overall decrease in cardiac output. A 2%-5% decrease in oxygen saturation indicates the nonprogressive stage of hypovolemia.)
The client with which laboratory result is at risk for hemorrhagic shock? International normalized ratio (INR) 7.9 Partial thromboplastin time (PTT) 12.5 seconds Platelets 170,000/mm³ (170 × 10⁹/L) Hemoglobin 8.2 g/dL (82 mmol/L)
International normalized ratio (INR) 7.9 (A client with a prolonged INR of 7.9 places a client at risk for hemorrhagic shock. Prolonged INR indicates that blood takes longer than normal to clot and increases the risk for bleeding. PTT of 12.5 seconds is low and puts this client at risk for clotting. A platelet value of 170,000/mm³ (170 × 10⁹/L) is normal and poses no risk for bleeding. Although a hemoglobin of 8.2 g/dL (82 mmol/L) is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.)
Which organ can tolerate hypoxia for 1 hour without permanent damage in a patient with hypovolemic shock? Liver Brain Heart Kidney
Kidney (Kidneys can tolerate hypoxia for 1 hour without permanent damage, but beyond this time the patient is at the risk of kidney failure. The liver, brain, and heart cannot tolerate hypoxia; it will lead to organ dysfunction.)
How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? PaCO₂ 58 mmHg Lactate 81 mg/dL (9.0 mmol/L) Partial thromboplastin time 64 seconds Potassium 2.8 mEq/L (2.8 mmol/L)
Lactate 81 mg/dL (9.0 mmol/L) (The client with septic shock and a lactate level of 81 mg/dL (0.9 mmoL/L) indicates that severe tissue hypoxia is present. Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid. Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis, but this value is decreased and is not consistent with septic shock.)
The expected outcome of the sepsis resuscitation bundle for a patient with septic shock has been met when which parameter is present? Lactate level of 4 mmol/L Mean arterial blood pressure of 55 mmHg Negative blood cultures after 24 hr Presence of anuria for less than 24 hr
Lactate level of 4 mmol/L (Effective fluid resuscitation will restore tissue perfusion, correcting lactic acidosis and meeting the goal of a lactate level of 4 mmol/L. Mean arterial pressure in septic shock should be maintained at 65 mm Hg for adequate tissue perfusion. Blood cultures may take 3 days to grow; appropriate treatment is initiated prior to culture results. The result of treatment of sepsis is to maintain a urine output of at least 20 mL/hr.)
Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? Localized erythema and edema Low-grade fever and mild hypotension Low oxygen saturation rate and decreased cognition Reduced urinary output and increased respiratory rate
Low-grade fever and mild hypotension (Low-grade fever and mild hypotension in a postoperative client indicate very early sepsis. With treatment, the probability of recovery is high.Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate severe sepsis. Reduced urinary output and increased respiratory rate indicate active (not early) sepsis.)
Which clinical symptoms in a postoperative patient indicate early sepsis with an excellent recovery rate if treated? Localized erythema and edema Low-grade fever and mild hypotension Low oxygen saturation rate and decreased cognition Reduced urinary output and an increased respiratory rate
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 an increased respiratory rate indicate severe sepsis.)
How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? Urine output 20 to 30 mL/hr for the last 4 hours Mean arterial pressure (MAP) 70 mmHg Albumin 3.5 g/dL (5.0 mcmol/L) Hemoglobin 7.6 g/dL (76 mmol/L)
Mean arterial pressure (MAP) 70 mmHg (A MAP of 70 mm Hg means that a positive outcome has occurred when plasma protein fraction (Plasmanate) has been administered. Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, and a desired outcome in shock.Urine output needs to 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 and does not improve an abnormal hemoglobin.)
A postoperative client is admitted to the intensive care unit (ICU) with hypovolemic shock. Which nursing action does the nurse delegate to an experienced unlicensed assistive personnel (UAP)? Obtain vital signs every 15 minutes. Measure hourly urine output. Check oxygen saturation. Assess level of alertness.
Measure hourly urine output. (The nurse delegates to an experienced ICU UAP the measurement of hourly urine output on a client with hypovolemic shock. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment. The nurse will evaluate the results.Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.)
A hypertensive crisis may occur if adrenergic (sympathomimetic) drugs are given along with which of the following drug classes? Alpha₁ blockers Direct renin inhibitors Monoamine oxidase inhibitors (MAOIs) Beta blockers
Monoamine oxidase inhibitors (MAOIs) (Adrenergic drugs combined with MAOIs may cause a possibly life-threatening hypertensive crisis. All of the other drugs listed are used to treat hypertension.)
Which are cardiovascular manifestations of hypovolemic shock? Select all that apply. Narrow pulse pressure Postural hypotension Decreased pulse rate Decreased cardiac output Bounding peripheral pulses
Narrow pulse pressure Postural hypotension Decreased cardiac output (In hypovolemic shock, total body fluid is reduced; therefore, the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.)
Which stage of hypovolemic shock is indicated by a pulse oximetry value of 93%? Initial stage Refractory stage Progressive stage Nonprogressive stage
Nonprogressive stage (In the nonprogressive stage of hypovolemic shock, the pulse oximetry value ranges from 90-95%. If the value is above 95%, it indicates the initial stage of hypovolemic shock. Any value below 70% indicates the refractory stage. In the progressive stage, the value lies between 75% and 80%.)
Which finding may reflect increased cardiac output in patients with septic shock? Bradycardia Decreased stroke volume Normal central venous pressure Increase in systolic blood pressure
Normal central venous pressure (Increased cardiac output is reflected by a normal central venous pressure (CVP). Increased cardiac output is reflected by tachycardia rather than bradycardia. Increased stroke volume and a normal systolic blood pressure may also reflect increased cardiac output.)
The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: Physical Assessment Findings: Pulse 140 beats/min and thready Blood pressure 60/40 mm Hg Respirations 40/min and shallow Diagnostic Findings: ABG respiratory acidosis Lactate level 63 mg/dL(7 mmol/L) All of these provider prescriptions are given for the client. Which does the nurse carry out first? Notify anesthesia for endotracheal intubation. Give Plasmanate 1 unit now. Give normal saline solution 250 mL/hr. Type and crossmatch for 4 units of packed red blood cells (PRBCs).
Notify anesthesia for endotracheal intubation. (The nurse must first notify anesthesia for endotracheal intubation for this client with hemorrhagic shock. Establishing an airway is the priority in all emergency situations.Although administering Plasmanate and normal saline, and typing and cross matching for 4 units of PRBCs are important actions, airway always takes priority.)
The nurse is caring for a patient with heart rate of 143 beats/min. For which manifestations does the nurse observe? Select all that apply. Palpitations Increased energy Chest discomfort Flushing of the skin Hypotension
Palpitations Chest discomfort Hypotension (Tachycardia is a heart rate greater than 100 beats/min; the patient with a tachydysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope ("blackout") from hypotension. Chest discomfort and palpitations may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue.In this situation, the patient will have pale, cool skin and not flushing of the skin. Also, reduced cardiac output and possible development of heart failure will cause fatigue and not increased energy.)
Which organ is responsible for releasing myocardial depressant factor that leads to heart damage as a result of multiple organ dysfunction syndrome (MODS)? Liver Brain Kidney Pancreas
Pancreas (Myocardial depressant factor is secreted from the ischemic pancreas and is responsible for causing profound damage to the heart in MODS. The liver, brain, and kidneys, in addition to the heart, are severely damaged but they do not release myocardial depressant factors.)
A patient in hypovolemic shock presents with a normal hematocrit and hemoglobin. What type of fluid should the nurse anticipate the health care provider will prescribe to restore oncotic pressure? Plasma Whole blood Ringer's lactate Packed red cells
Plasma (The ideal intervention for restoring osmotic pressure in a patient with normal hematocrit and hemoglobin is plasma. Plasma protein fractions and synthetic plasma expanders are used to increase fluid volume. Whole blood is suitable for replacing large blood losses in patients with a decrease in hemoglobin and hematocrit levels. Ringer's lactate does not restore oncotic pressure; it is a crystalloid that restores fluid volume and is used in instances where the patient needs volume expansion and correction of acidosis. Packed red cells are chosen for moderate blood losses when the patient needs red blood cells without added fluid volume.)
Which problem places a client at highest risk for sepsis? Pernicious anemia Pericarditis Post kidney transplant Client owns an iguana
Post kidney transplant (A client with post kidney transplant is the highest risk for sepsis. This client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms.Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a greater risk for infection, sepsis, and death.)
Which stage of hypovolemic shock is a medical emergency and requires immediate intervention? Initial stage Refractory stage Progressive stage Nonprogressive stage
Progressive stage (The progressive stage of shock is a medical emergency that requires immediate intervention because compensatory mechanisms may be unable to deliver an adequate amount of oxygen to the vital organs. If this condition is left untreated even for an hour, it will lead to multiple organ dysfunction syndrome and even death. At the initial stage, the compensatory mechanisms are efficient enough to maintain normal oxygenation and perfusion rates of the vital organs; thus, immediate interventions are not required. The refractory stage involves excessive cell damage and tissue death, because tissue perfusion is blocked at this stage due to an excessive decrease in mean arterial pressure. The nonprogressive stage is not a medical emergency. If supportive interventions are performed, a patient can remain in the nonprogressive stage for hours without any damage to the vital organs.)
What part of the conduction system is responsible for the contraction of ventricles? Purkinje fibers Sinoatrial (SA) node Transitional cell zone Atrioventricular (AV) node
Purkinje fibers (At the ends of both the right and the left bundle branch systems are the Purkinje fibers. These cells are responsible for the rapid conduction of electrical impulses throughout the ventricles, leading to ventricular depolarization and subsequent ventricular muscle contractions. The sinoatrial (SA) node is responsible for generating impulses for the heart. Impulses from the SA move directly through atrial muscle and lead to atrial depolarization. The atrioventricular (AV) node carries impulses from the SA node to the bundle of His to be transmitted to the ventricles. The transitional cell zone (transitional cells) causes impulses to slow down or to be delayed in the AV node before proceeding to the ventricles.)
A patient's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? Normal sinus rhythm Sinus bradycardia Sinus tachycardia Sinus rhythm with premature ventricular contractions
Sinus tachycardia (These are the characteristics of sinus tachycardia.A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions.)
What is the component of colloid solutions that is helpful in managing hypovolemic shock through the intravenous route? Salts Sugars Starches Minerals
Starches (Colloid solutions are mainly composed of larger molecules like starches and proteins. These molecules help to maintain the oncotic pressure of the intravascular fluid and prevent fluid loss. Salts, sugars, and minerals are components of crystalloids, not colloids.)
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? Hypotension Bradypnea Heart blocks Tachycardia
Tachycardia (Tachycardia is an early symptom of shock. Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal and not abnormally low. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock and are related to lack of oxygen to the heart.)
What typical sign/symptom indicates the early stage of septic shock? Pallor and cool skin Blood pressure 84/50 mm Hg Tachypnea and tachycardia Respiratory acidosis
Tachypnea and tachycardia (Early signs/symptoms of systemic inflammatory response syndrome include rapid respiratory rate, leukocytosis, and tachycardia. The early stage of septic shock precedes sepsis.In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis and not acidosis occurs early in shock because of an increased respiratory rate.)
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? Temperature Pulse Respiration Blood pressure
Temperature (A postoperative client's temperature may differentiate pulmonary embolism from early sepsis when the client complains of feeling light-headed and anxious. A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia (pulse), tachypnea (respiration), and hypotension (blood pressure).)
How does the nurse recognize that atropine has produced a positive outcome for the patient with bradycardia? The patient states he is dizzy and weak. The nurse notes dyspnea. The patient has a heart rate of 42 beats/min. The monitor shows an increase in heart rate.
The monitor shows an increase in heart rate. (An expected outcome after the administration of atropine is an increased heart rate. By definition, the bradydysrhythmia has resolved when the heart rate is greater than 60 beats/min.Dizziness and weakness indicate symptoms of decreased cerebral perfusion and intolerance to the bradydysrhythmia. Dyspnea indicates intolerance to the bradydysrhythmia. A heart rate of 42 beats/min after atropine has been given indicates that bradycardia is unresolved.)
The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? The patient is semi-recumbent in bed. Chest leads are placed as for the previous ECG. The patient is instructed to breathe deeply through the mouth. The patient is instructed to lie still.
The patient is instructed to breathe deeply through the mouth. (While obtaining a 12-lead ECG, remind the patient to be as still as possible in a semi-reclined position, breathing normally. Any repetitive movement will cause artifact and could lead to inaccurate interpretation of the ECG. Normal breathing is required or artifacts will be observed, perhaps leading to inaccurate interpretation of the ECG.Placing the patient in a semi-reclined position is correct and does not require the nurse to intervene. ECGs are valid when electrode placement is identical at each test. The patient must lie still to avoid artifacts and inaccurate interpretation of the ECG.)
Which statement accurately describes the area of the heart that initiates the cardiac cycle? The ventricles' Purkinje fibers are responsible for the initial cardiac impulse. The bundle of His acts to initiate cardiac contraction in the atria with a resulting QRS complex. The atrioventricular area acts as the primary pacemaker and produces the P wave on the ECG. The sinoatrial (SA) node is the primary pacemaker of the heart whose activity is reflected in the P wave on the ECG.
The sinoatrial (SA) node is the primary pacemaker of the heart whose activity is reflected in the P wave on the ECG. (The SA node is the heart's primary pacemaker causing atrial depolarization, reflected in the P wave on the ECG. The atrial (A) junction and atrioventricular (AV) node receive conduction from the SA node, delaying conduction before sending the impulse to the ventricles; this is reflected in the PR segment. The bundle of His extends down the interventricular septum to both ventricles. The Purkinje fibers cause rapid conduction of impulses throughout the ventricles, causing ventricular depolarization and contraction consistent with the QRS complex.)
What area of the cardiac conduction system is responsible for generating the electrical impulse in the heart? AV node Bundle of His Purkinje fibers The sinus node
The sinus node (The sinus node, or SA node, is where conduction begins. This node is located close to the surface of the right atrium. After leaving the SA node, the impulse travels to the AV node, then to the bundle of His, and on to the Purkinje fibers.)
Which clients are at immediate risk for hypovolemic shock? Select all that apply. Unrestrained client in a motor vehicle collision (MVC) Construction worker Athlete Surgical intensive care unit (SICU) client 85-year-old with gastrointestinal (GI) virus
Unrestrained client in a motor vehicle collision (MVC) Surgical intensive care unit (SICU) client 85-year-old with gastrointestinal (GI) virus (Clients who are immediate risk for hypovolemic shock include: the unrestrained client in a (MVC), the SICU client, and the 85-year-old client with GI virus. The client who is unrestrained in a MVC is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock, especially if a gastrointestinal virus is present that results in fluid losses.Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock. They may, however, be at risk for dehydration.)
A patient is receiving antineoplastic chemotherapy. Which measure does the nurse teach that will help prevent infection and sepsis? Drink only bottled water. Use disposable dishes. Wash the dishes in the dishwasher. Avoid being in the same room as the family pet.
Wash the dishes in the dishwasher. (Dishes should be washed in hot, soapy water or in a dishwasher to thoroughly cleanse them; there is no need to use disposable tableware. Water that has been standing longer than 15 minutes should be discarded; however, bottled water is not necessary. The patient may be in the same room as, as well as touch, the family pet (with the exception of changing a litterbox—this should not be done); however, the patient should wash the hands thoroughly with an antimicrobial soap after touching pets.)
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."
a. "Clean the skin and clip hairs if needed." (To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.)
A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."
a. "High glucose is common in shock and needs to be treated." (High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.)
The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.
a. Administer antibiotics. b. Draw serum lactate levels. e. Obtain blood cultures. (Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.)
A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours
a. Alert and oriented, answering questions (Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.)
The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration
a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition (Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.)
The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion
a. Anaerobic metabolism c. Hypotension The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.)
A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain "universal" donor blood. d. Prepare the client for emergency surgery.
a. Apply personal protective equipment. (The nurse's priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery.)
The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures
a. Assessing and identifying clients at risk c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures (Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.)
A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance
a. Bringing the client warm blankets d. Reorienting the client as needed e. Sitting with the client for reassurance (The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.)
The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mmHg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours
a. Client with a blood pressure change of 128/74 to 110/88 mmHg (This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.)
The nurse is presenting information to a class of students about adrenergic drugs. Which are the effects of drugs that stimulate the sympathetic nervous system? (Select all that apply.) a. Dilation of bronchioles b. Constriction of bronchioles c. Decreased heart rate d. Increased heart rate e. Dilated pupils f. Constricted pupils g. Glycogenolysis
a. Dilation of bronchioles d. Increased heart rate e. Dilated pupils g. Glycogenolysis (Stimulation of the sympathetic nervous system causes bronchodilation, increased heart rate, pupil dilation, and glycogenolysis as well as many other effects. The other responses are effects that occur as a result of the stimulation of the parasympathetic nervous system.)
When a patient is taking an adrenergic drug, the nurse expects to observe which effect? a. Increased heart rate b. Bronchial constriction c. Constricted pupils d. Increased intestinal peristalsis
a. Increased heart rate (Increased heart rate is one of the effects of adrenergic drugs. Sympathetic nervous system stimulation also results in bronchodilation, dilated pupils, and decreased gastrointestinal mobility, depending upon which receptors are stimulated.)
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave
a. Mid-sternal chest pain (Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.)
A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the client's bed. d. Tell the client everything possible is being done.
a. Offer to remain with the client for awhile. (The nurse's presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the client's blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client's safety. Telling a confused client that everything is being done is not the most helpful response.)
When an adrenergic drug stimulates beta₁-adrenergic receptors, the result is an increased force of contraction, which is known as what type of effect? a. Positive inotropic b. Anti-adrenergic c. Negative dromotropic d. Positive chronotropic
a. Positive inotropic (An increased force of contraction is known as a positive inotropic effect.)
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."
b. "Avoid straining while having a bowel movement." (Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.)
A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grandkids are so excited to have me coming home!"
b. "I hope I can get my water turned back on when I get home." (All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.)
A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the client's tissue perfusion further. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.
b. Assess the client's tissue perfusion further. (Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.)
A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.
b. Drink fluids on a regular schedule. (Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn't give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.)
A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.
b. Ensure the client has a patent airway. (Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.)
An adrenergic agonist is ordered for a patient in shock. The nurse will note that this drug has had its primary intended effect if which expected outcome occurs? a. Volume restoration b. Increased cardiac output c. Decreased urine output d. Reduced anxiety
b. Increased cardiac output (For a patient in shock, a primary benefit of an adrenergic agonist drug is to increase cardiac output. A drug in this category should not be used in place of volume restoration, nor does it provide volume restoration (IV fluids do this). Adrenergic agonists may enhance urine output if cardiac output and perfusion to the kidneys increase. These drugs do not reduce anxiety.)
A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm³
b. Lactate: 6 mmol/L (A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm³ is slightly high but is not as critical as the lactate level.)
A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.
b. Lower blood volume lowers MAP. (Lower blood volume will decrease MAP. The other answers are not accurate.)
A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.
b. Measure urine output from the catheter. (Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.)
The nurse recognizes that adrenergic drugs cause relaxation of the bronchi and bronchodilation by stimulating which type of receptors? a. Dopaminergic b. Beta₁ adrenergic c. Beta₂ adrenergic d. Alpha₁ adrenergic
c. Beta₂ adrenergic (Stimulation of beta2-adrenergic receptors results in bronchodilation. The other choices are incorrect.)
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability
c. Level of consciousness (A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.)
A nurse caring for a client notes the following assessments: white blood cell count 3800/mm³ blood glucose level 198 mg/dL temperature 96.2° F (35.6° C) What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.
c. Notify the health care provider immediately. (This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.)
A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable ("smart") IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs
c. Removing the IV bag from the brown plastic cover (Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a "smart" pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.)
A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mmHg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr
c. Report of chest heaviness (Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client's previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.)
The nurse is aware that adrenergic drugs produce effects similar to which of these nervous systems? a. Central nervous system b. Somatic nervous system c. Sympathetic nervous system d. Parasympathetic nervous system
c. Sympathetic nervous system (Adrenergic drugs mimic the effects of the sympathetic nervous system.)
The nurse is preparing to administer dopamine. Which is the correct technique for administering dopamine? a. Orally b. Intravenous (IV) push injection c. Intermittent IV infusions (IV piggyback) d. Continuous IV infusion with an infusion pump
d. Continuous IV infusion with an infusion pump (Dopamine is available only as an IV injectable drug and is given by continuous infusion, using an infusion pump. The other options are incorrect.)
A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
d. Ventricular and atrial depolarizations are initiated from different sites. (Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.)
