Chapter 12: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The primary care provider orders stat administration of an antibiotic. Which additional order should the nurse complete first? A. Blood cultures B Chest x-ray C. Foley insertion D. Serum electrolytes

A. Blood cultures

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

a. "The action of the machine will improve blood supply to the damaged heart."

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

a. Assess the blood pressure palpation

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

a. Blood pressure c. Level of consciousness f. Urine output

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

a. Cardiac index (CI) of 2.5 L/min/m2

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

a. Central nervous system

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

a. Dobutamine

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

a. Documentation of insertion date

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

a. High pulmonary artery diastolic pressure and low cardiac output

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

a. Insertion of an 18-gauge peripheral intravenous line

The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate of 45 beats/min, and respirations of 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

a. The patient is developing neurogenic shock.

The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.

b. Additional interventions are indicated.

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

b. Document the patient's response. d. Notify the blood bank. e. Notify the physician. f. Stop the transfusion.

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? a. Diphenhydramine 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone 125 mg intravenously d. Ranitidine 50 mg intravenously

b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously

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

b. Hemoglobin and hematocrit results indicate hemodilution.

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

b. Lactate 6 mmol/L

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

b. Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain

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

b. Swelling at the IV site

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output

d. Low systemic vascular resistance and high cardiac output

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 primary care provider rounds, the nurse reviews the orders and questions which order? a. Administer acetaminophen 650-mg suppository prn every 6 hours for pain. b. Titrate dopamine intravenously for blood pressure < 90 mm Hg systolic. c. Complete neurological assessment every 4 hours for the next 24 hours. d. Administer furosemide 20 mg IV every 4 hours for a CVP > 20 mm Hg.

b. Titrate dopamine intravenously for blood pressure < 90 mm Hg systolic.

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102° F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids

c. A patient with a 2-day history of nausea, vomiting, and diarrhea

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? a. Administration of atropine sulfate b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine

c. Application of slow rewarming measures

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

c. Assess core body temperature.

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

c. Enteral feedings

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

c. Lactated Ringer's bolus

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

c. Reduce the rate of dobutamine.

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. Titrate rate of blood administration to patient response.

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

d. Increased sympathetic stimulation

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

d. Isotonic fluid challenge

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

d. Right atrial pressure and urine output

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

d. The patient is at risk for developing hypovolemic shock.

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

d. Urine output of 0.5 mL/kg/hr

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. pH 7.30, CO2 45, HCO3 18