Chapter 14 overview of shock and sepsis

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.

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

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

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

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 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

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 clients 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 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 mm Hg 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 mm Hg

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.

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 clients bed. d. Tell the client everything possible is being done.

a. Offer to remain with the client for awhile.

2. A nurse is caring for a client after surgery. The clients 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 clients tissue perfusion further. c. Document the findings in the clients chart. d. Increase the rate of the clients IV infusion

b. Assess the clients tissue perfusion further.

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 laceration d. Take medications as prescribed.

b. Drink fluids on a regular schedule.

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.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The clients 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.

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

1. A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients 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.

4. 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.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and 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.

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

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 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

c. Report of chest heaviness

The nurse explains the purpose of an infusion of albumin 5% to a patient recovering from hypovolemic shock. Which statement indicates that the patient understands the instructions? 1) "It is a protein that pulls water into my blood vessels." 2) "It is a protein that causes my kidneys to conserve fluid." 3) "It is a super-concentrated salt solution that helps me conserve body fluid." 4) "It is a liquid that has electrolytes in it to pull water into my blood vessels."

1) "It is a protein that pulls water into my blood vessels."

A patient is prescribed epinephrine for the prevention of anaphylactic shock. The patient states, "I thought shock was about heart failure." Which response by the nurse is most appropriate? 1) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." 2) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." 3) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure." 4) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure."

1) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood."

The nurse is administering albumin 5% to a patient in shock. Which nursing action is appropriate when assessing this patient? 1) Auscultate breath sounds for crackles 2) Auscultate breath sounds for hyperresonance 3) Auscultate breath sounds for inspiratory stridor 4) Auscultate for an absence of breath sounds in the lower lobes

1) Auscultate breath sounds for crackles

Which will the nurse closely monitor due to the pathophysiology associated with early shock? Select all that apply. 1) Bowel sounds 2) Level of consciousness 3) Urine output 4) Peripheral pulses 5) Heart rate

1) Bowel sounds 3) Urine output 4) Peripheral pulses

A patient is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this patient for when administering the infusion? Select all that apply. 1) Confusion 2) Tachycardia 3) Disorientation 4) Muscle spasms 5) Gastrointestinal bleeding

1) Confusion 2) Tachycardia 3) Disorientation 4) Muscle spasms

A nurse is caring for a patient who was involved in a motor vehicle accident who has lost approximately 1,500 mL of blood. Based on this data, which type of shock is the patient experiencing? 1) Hypovolemic 2) Cardiogenic 3) Distributive 4) Obstructive

1) Hypovolemic

The nurse is preparing an educational session on sepsis. Which should the nurse include as a major risk factor for the development of this health problem? 1) Immunosuppression 2) Elevated temperature 3) Pneumococcal bacteria 4) Leukocytosis on the complete blood count

1) Immunosuppression

The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a patient with septicemia. Which intervention will address this patient's health problem? 1) Monitor for cyanosis. 2) Monitor heart rate every hour. 3) Assess temperature every four hours. 4) Monitor pupil reactions every eight hours.

1) Monitor for cyanosis.

Which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock? Select all that apply. 1) Pallor 2) Increased bowel sounds 3) Restlessness 4) Decreased blood glucose 5) Increased respiratory rate

1) Pallor 3) Restlessness 5) Increased respiratory rate

An older adult patient is recovering in the intensive care unit (ICU) from septicemia. Which intervention will help prevent further infection for this patient? 1) Provide oral and skin care 2) Implement sterile wound care 3) Encourage turn, cough, and deep breathe every shift 4) Place the Foley drainage on the bed at the patient's feet

1) Provide oral and skin care

A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with late septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. 1) Shallow respirations 2) Lethargic mental status 3) Decreased urine output 4) Normal blood pressure 5) Warm and flushed skin 6) Rapid and deep respirations

1) Shallow respirations 2) Lethargic mental status 3) Decreased urine output

A patient in neurogenic shock is receiving rapid intravenous fluids. Which assessment finding indicates the need for additional nursing interventions? 1) The patient's mean arterial pressure (MAP) is 60 mmHg. 2) The patient is unconscious. 3) The patient has received two liters of infused fluid. 4) The patient is perspiring heavily

1) The patient's mean arterial pressure (MAP) is 60 mmHg.

A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (Record your answer using a whole number.) ____ mL/hr

142 mL/hr

The nurse is preparing to administer diphenhydramine to a patient who is experiencing a severe allergic reaction to peanuts. Which information about the drug should the nurse provide to the patient? 1) "This is the medication of choice to treat airway obstruction." 2) "This medication will help relieve your itching and runny nose." 3) "This medication will prevent you from going into anaphylactic shock." 4) "This medication will take a while to be effective but will control your symptoms for several hours."

2) "This medication will help relieve your itching and runny nose."

A nurse working in the intensive care unit (ICU) is caring for a patient in the refractory stage of shock. When planning care, which does the nurse anticipate? 1) A subtle change in heart rate 2) A change from aerobic to anaerobic metabolism 3) The development of hyperglycemia 4) The development of cardiac dysrhythmias

2) A change from aerobic to anaerobic metabolism

A patient is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this patient? Select all that apply. 1) Pain 2) Fever 3) Edema 4) Anorexia 5) Tachycardia

2) Fever 4) Anorexia 5) Tachycardia

A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with early septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. 1) Shallow respirations 2) Normal blood pressure 3) Warm and flushed skin 4) Lethargic mental status 5) Decreased urine output 6) Rapid and deep respirations

2) Normal blood pressure 3) Warm and flushed skin 6) Rapid and deep respirations

The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic, hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient? 1) Starting two large intravenous catheters 2) Notifying the Rapid Response Team 3) Calling the patient's physician to report the changes 4) Placing oxygen on the patient

2) Notifying the Rapid Response Team

Which is the highest priority nursing action when providing care to a patient with shock? 1) Starting two large intravenous catheters 2) Recognizing early clinical manifestations 3) Administering high-flow oxygen 4) Calling for help immediately

2) Recognizing early clinical manifestations

The nurse is providing care to a patient who is admitted with cardiogenic shock. The nurse administers the prescribed atropine with no results. Which prescription does the nurse anticipate from the health-care provider based on this data? 1) A beta blocker 2) Transcutaneous pacing 3) Cardiac defibrillation 4) A preload reducer

2) Transcutaneous pacing

The nurse has just completed the assessment of a patient admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this patient? 1) Ineffective Coping 2) Deficient Fluid Volume 3) Decreased Cardiac Output 4) Ineffective Airway Clearance

3) Decreased Cardiac Output

The nurse is providing care for a patient receiving treatment for cardiogenic shock. Which assessment finding indicates that the compensatory mechanism of vasoconstriction has occurred in this patient? 1) Increased heart rate 2) Increased injection fraction 3) Decreased urine output 4) Decreased temperature

3) Decreased urine output

An older adult patient is experiencing hypovolemic shock. Which is the priority intervention for this patient? 1) Assessing the cause of bleeding 2) Providing replacement of volume 3) Establishing invasive cardiac monitoring 4) Administering analgesics for control of pain

3) Establishing invasive cardiac monitoring

The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment findings support the nurse's concern? Select all that apply. 1) Rapid weak pulse 2) Normal respirations 3) Normal blood pressure 4) Slight increase in pulse 5) Prolonged capillary refill time

3) Normal blood pressure 4) Slight increase in pulse 5) Prolonged capillary refill time

The nurse is providing care to a patient admitted to the emergency department (ED) with a gunshot wound and profound blood loss. Which order does the nurse anticipate for this patient? 1) Normal saline 2) Dextrose in water 3) Packed red blood cells 4) Albumin

3) Packed red blood cells

A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most appropriate? 1) Starting an 18-gauge intravenous catheter in the patient's nondominant hand 2) Ordering a type and cross-match of packed red blood cells 3) Preparing to assist with central line placement 4) Inserting a nasogastric tube

3) Preparing to assist with central line placement

The nurse is providing care to a patient who is admitted to the emergency department with symptoms of a myocardial infarction (MI). Which is the primary purpose of the interventions administered to this patient? 1) Providing pain relief 2) Preventing extension of damage 3) Preventing cardiogenic shock 4) Reducing blood pressure

3) Preventing cardiogenic shock

A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the nurse anticipate for this patient? 1) Increased cardiac output 2) Stabilization of fluid loss 3) Urinary output of at least 30 mL/hour 4) Vasoconstriction and increased blood pressure

3) Urinary output of at least 30 mL/hour

The nurse is conducting medication teaching for a patient who is prescribed an epi-pen. Which statements made by the patient indicates the need for additional instruction? 1) "I will carry an epi-pen with me at all times." 2) "I will check the expiration date on my epi-pen regularly." 3) "I should hold the epi-pen in place for 10 seconds after injection." 4) "I should use the epi-pen to inject the drug into my abdominal wall."

4) "I should use the epi-pen to inject the drug into my abdominal wall."

During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing the patient? 1) Lethargy 2) Hypotension 3) Respiratory alkalosis 4) Subtle changes in heart rate

4) Subtle changes in heart rate

The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is appropriate for this patient during the initial compensatory phase? 1) Placing a cool blanket over the patient 2) Raising the patient's head to a 30-degree angle 3) Positioning the patient in the left-lateral recumbent position 4) Turning the patient's head to one side if no neck injury is suspected

4) Turning the patient's head to one side if no neck injury is suspected