Chapter 26 Questions

14. A vasoconstrictor used to treat shock is a. adrenaline. b. Nipride. c. Dobutrex. d. adenosine.

ANS: A Adrenaline is a vasoconstrictor, Nipride is a vasodilator, Dobutrex is an inotrope, and adenosine is an antidysrhythmic.

17. The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy b. Heart rate of 118 beats/min c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

ANS: A Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status.

3. The nursing measure that can best enhance large volumes of fluid replacement in hypovolemic shock is a. insertion of a large-diameter peripheral intravenous catheter. b. positioning the patient in the Trendelenburg position. c. forcing at least 240 mL of fluid each hour. d. administering intravenous lines under pressure.

ANS: A Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.

23. The most common site for sepsis and septic shock is a. the respiratory system. b. the gastrointestinal system. c. the genitourinary system. d. the circulatory system.

ANS: A The respiratory system is the most common site of infection producing severe sepsis and septic shock followed by the genitourinary and gastrointestinal systems.

3. Evidence-based guidelines for the treatment of septic shock include which of the following? (Select all that apply.) a. Fluid resuscitation to maintain central venous pressure at 8 mm Hg or greater b. Low-dose dopamine for renal protection c. High-dose corticosteroids d. Administration of activated protein C e. Achieve central venous oxygen saturation of 70% or more

ANS: A, D, E There is no evidence to support the use of dopamine; low-dose steroids are part of the sepsis management bundle.

24. Profound weight loss in patients with SIRS or MODS is the result of a. hypometabolism. b. hypermetabolism. c. hyperglycemia. d. intolerance to enteral feedings.

ANS: B Hypermetabolism in SIRS or MODS results in profound weight loss, cachexia, and loss of organ function. The goal of nutritional support is the preservation of organ structure and function. Although nutritional support may not definitely alter the course of organ dysfunction, it prevents generalized nutritional deficiencies and preserves gut integrity. Enteral nutrition may exert a physiologic effect that downregulates the systemic immune response and reduces oxidate stress.

3. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles b. Heart rate 45 beats/min c. Cool, clammy extremities d. Temperature 101.2°F (38.4°C)

ANS: B Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

17. The difference between primary and secondary multiple organ dysfunction syndrome (MODS) is that primary MODS is the result of a. widespread systemic inflammation that results in dysfunction of organs not involved in the initial insult. b. direct organ injury. c. disorganization of the immune system response. d. widespread disruption of the coagulation system.

ANS: B Organ dysfunction may be the direct consequence of an initial insult (primary MODS) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.

12. Signs of hypovolemia in the trauma patient include a. distended neck veins. b. a decreased level of consciousness. c. bounding radial and pedal pulses. d. a widening pulse pressure.

ANS: B Signs of underperfusion include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure.

19. Clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which symptom below is indicative of hepatic insufficiency? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase

ANS: C Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism.

21. A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to note to support this diagnosis? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase

ANS: C Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism. PTS: 1 DIF: Cognitive Level: Applying REF: p. 832 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

2. Hypovolemic shock that results from an internal shifting of fluid from the intravascular space to the extravascular space is known as a. absolute hypovolemia. b. distributive hypovolemia. c. relative hypovolemia. d. compensatory hypovolemia.

ANS: C Hypovolemia results in a loss of circulating fluid volume. A decrease in circulating volume leads to a decrease in venous return, which results in a decrease in end-diastolic volume or preload.

4. An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

ANS: C Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

16. When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Maintaining a cool room temperature for a patient with neurogenic shock d. Increasing the nitroprusside infusion rate for a patient with a very high SVR

ANS: C Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

18. The gastrointestinal system is a common target organ for MODS related to a. anorexia. b. limited or absent food ingestion. c. disruption of the mucosal barrier from hypoperfusion. d. a decrease in hydrochloric acid secretion.

ANS: C With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and MODS.

7. Which of the following drugs promotes bronchodilation and vasoconstriction? a. Solu-Medrol b. Gentamicin c. Atropine d. Epinephrine

ANS: D Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators.

8. A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine

ANS: D Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators. PTS: 1 DIF: Cognitive Level: Applying REF: p. 814 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

1. The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Give vancomycin 1 g IV. b. Obtain blood and urine cultures c. Start norepinephrine 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation above 95%.

ANS: E, D, C, B, A The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics.

1. A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many milliliters per hour?

ANS: 27 To administer the dobutamine at the prescribed rate of 5 mcg/kg/min from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hr.

2. The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? a. Absolute hypovolemia b. Distributive hypovolemia c. Relative hypovolemia d. Compensatory hypovolemia

ANS: A Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure. Relative hypovolemia occurs when vasodilation produces an increase in vascular capacitance relative to circulating volume. PTS: 1 DIF: Cognitive Level: Applying REF: p. 805 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

15. A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.

ANS: A Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

4. The main cause of cardiogenic shock is a. an inability of the heart to pump blood forward. b. hypovolemia, resulting in decreased stroke volume. c. disruption of the conduction system when re-entry phenomenon occurs. d. an inability of the heart to respond to inotropic agents.

ANS: A Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.

4. The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system

ANS: A Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure. PTS: 1 DIF: Cognitive Level: Applying REF: p. 807 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

22. The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Give epinephrine. b. Administer diphenhydramine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count (CBC)

ANS: A Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.

1. A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.

ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock require large amounts of fluid replacement. If the patient remains hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.

9. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. A pulmonary artery catheter is placed. Which of the following hemodynamic values would you expect to find? a. Cardiac output of 8 L/min b. Right atrial pressure of 17 mm Hg c. Pulmonary artery wedge pressure of 23 mm Hg d. Systemic vascular resistance of 1100

ANS: A Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.

10. A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/s/cm-5

ANS: A Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 821|Box 34-17 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

25. An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. Sepsis b. Delirium c. Adult respiratory distress syndrome d. Acute kidney injury

ANS: A Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the presence of an existing infection. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 821 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

15. A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine

ANS: A Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

3. A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag

ANS: A Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest. PTS: 1 DIF: Cognitive Level: Applying REF: p. 807 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

27. A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation c. Injury to the hypothalamus d. Focal injury to cerebral hemispheres

ANS: A Neurogenic shock can be caused by anything that disrupts the sympathetic nervous system (SNS). The problem can occur as the result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain. The most common cause is spinal cord injury (SCI). PTS: 1 DIF: Cognitive Level: Understanding REF: p. 815 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

6. With anaphylactic shock, which mechanism results in a decreased cardiac output? a. Peripheral vasodilation b. Increased cardiac output c. Decreased alveolar ventilation d. Fluid retention resulting in congestive heart failure

ANS: A Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output.

7. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility

ANS: A Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output. PTS: 1 DIF: Cognitive Level: Applying REF: p. 811|p. 813|Box 34-10 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

15. Which of the following clinical manifestations is not suggestive of systemic inflammatory response syndrome (SIRS)? a. Temperature of 37.5° C b. Heart rate of 95 beats/min c. Respiratory rate of 24 breath/min d. White blood cell (WBC) count of 15,000 cells/mm3

ANS: A SIRS occurs when two or more of four clinical manifestations are present in the patient at high risk. These manifestations are temperature less than 36° C or greater than 38° C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min or PaCO2 less than 32 mm Hg, or WBC greater than 12,000 cells/mm3 or less than 4000 cells/mm3 or greater than 10% immature (band forms).

19. During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Decreased bowel sounds c. Heart rate 112 beats/min d. Pale, cool, and dry extremities

ANS: A The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

14. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

ANS: A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock.

10. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. Which of the following is the pathophysiologic mechanism that results in septic shock? a. Bacterial toxins lead to vasodilation. b. Increased white blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. An increase of white blood cells leads to decreased red blood cell production and anemia.

ANS: A The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages.

11. A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss

ANS: A The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 817 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

1. The key to treatment of septic shock is finding the cause of the infection. Which of the following cultures are obtained before antibiotic therapy is initiated? (Select all that apply.) a. Blood cultures x 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. CBC with differential

ANS: A, B, C, D A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures.

MULTIPLE RESPONSE 1. A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply.) a. Blood cultures 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. Complete blood count (CBC) with differential

ANS: A, B, C, D A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 822 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

2. Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

ANS: A, B, C, D Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

2. Which of the following historical findings would indicate a high risk for latex allergy? (Select all that apply.) a. Allergic reaction to anesthetics b. Eczema of the hands c. Congenital urologic disorder d. Asthma e. Health care worker

ANS: A, B, C, E Prevention of anaphylactic shock is one of the primary responsibilities of nurses in critical care areas. Preventive measures include the identification of patients at risk and cautious assessment of each patient's response to the administration of medications, blood, and blood products. A complete and accurate history of each patient's allergies is an essential component of preventive nursing care. In addition to a list of the allergies, a detailed description of the type of response for each one should be obtained.

1. A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

ANS: A, B, D, E All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.

3. The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone

ANS: A, C, D There is no evidence to support the use of low-dose dopamine to maintain urine output. An adrenocorticotropic hormone (ACTH) stimulation test should not be used to identify patients who need hydrocortisone. PTS: 1 DIF: Cognitive Level: Applying REF: p. 804|p. 821|Box 34-17 OBJ: Nursing Process Step: Planning TOP:

16. The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure

ANS: B According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of presentation 1. Measure lactate level. 2. Obtain blood cultures prior to administration of antibiotics. 3. Administer broad spectrum antibiotics. 4. Administer 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. PTS: 1 DIF: Cognitive Level: Applying REF: p. 821|Box 34-17 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

11. Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since being admitted.

ANS: B Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

24. After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

ANS: B Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.

9. Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

ANS: B Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

23. Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's heart rate is 110 beats/minute.

ANS: B Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy.

20. A patient is admitted to the intensive care unit after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. DIC is known to occur in patients with retained placental fragments. What is the result of DIC? a. Hypersensitive response to an antigen, resulting in anaphylaxis b. Depletion of clotting factors and excessive fibrinolysis, resulting in simultaneous microvascular clotting and hemorrhage c. Vasodilatation, resulting in hypotension d. Septic shock, resulting in vasodilation and decreased perfusion

ANS: B DIC results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways.

22. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume

ANS: B Disseminated intravascular coagulation (DIC) results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 833 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

11. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. The medical management of the patient's condition is aimed toward a. limiting fluids to minimize the possibility of congestive heart failure. b. finding and eradicating the cause of infection. c. discontinuing invasive monitoring as a possible cause of sepsis. d. administering vasodilator substances to increase blood flow to vital organs.

ANS: B Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.

12. A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs

ANS: B Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions. PTS: 1 DIF: Cognitive Level: Applying REF: p. 822 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

26. The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS? a. Patient experiences hypometabolism. b. Patient experiences hypermetabolism. c. Patient experiences anorexia. d. Patient has gut dysfunction.

ANS: B Hypermetabolism in systemic inflammatory response syndrome (SIRS) or multiple-organ dysfunction syndrome (MODS) results in profound weight loss, cachexia, and loss of organ function. The goal of nutritional support is the preservation of organ structure and function. Although nutritional support may not definitely alter the course of organ dysfunction, it prevents generalized nutritional deficiencies and preserves gut integrity. Enteral nutrition may exert a physiologic effect that downregulates the systemic immune response and reduces oxidate stress. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 834 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

18. A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.

ANS: B Organ dysfunction may be the direct consequence of an initial insult (primary multiple-organ dysfunction syndrome [MODS]) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 823 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

1. Shock syndrome can best be described as a a. physiologic state resulting in hypotension and tachycardia. b. generalized systemic response to inadequate tissue perfusion. c. degenerative condition leading to death. d. condition occurring with hypovolemia that results in irreversible hypotension.

ANS: B Shock is a complex pathophysiologic process that often results in multiple organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

1. A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute, widespread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension.

ANS: B Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 801 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

13. A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness c. Bounding radial and pedal pulses d. Widening pulse pressure

ANS: B Signs of hypovolemia include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 805 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

22. Which medication is not recommended in the treatment of shock-related lactic acidosis? a. Glucose b. Sodium bicarbonate c. Vasoconstrictor d. Large quantity of crystalloids fluids

ANS: B Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.

24. The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep mean arterial blood pressure greater than 65 mm Hg. d. Administer crystalloid fluids.

ANS: B Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution. PTS: 1 DIF: Cognitive Level: Applying REF: p. 804 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

7. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% albumin infusion b. furosemide (Lasix) IV c. epinephrine (Adrenalin) drip d. hydrocortisone (Solu-Cortef)

ANS: B The PAWP indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

20. A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

ANS: B The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented.

8. The patients at highest risk for neurogenic shock are those who have had a. a stroke. b. a spinal cord injury. c. Guillain-Barré syndrome. d. a craniotomy.

ANS: B The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.

9. A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor

ANS: B The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion. PTS: 1 DIF: Cognitive Level: Applying REF: p. 815 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

2. A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

ANS: B The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.

2. A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure e. Decreased pulmonary artery occlusion pressure

ANS: B, C, D Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min; cool, pale, moist skin; weak, thready pulse; and increased right atrial pressure and pulmonary artery occlusion pressure. PTS: 1 DIF: Cognitive Level: Applying REF: p. 809|Box 34-7 OBJ: Nursing Process Step: Planning TOP: Shock MSC: NCLEX: Physiologic Integrity

6. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response

ANS: C Immunoglobulin E (IgE) is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body, the preformed IgE antibody reacts with it, and a secondary immune response occurs. PTS: 1 DIF: Cognitive Level: Applying REF: p. 811 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

21. Laboratory values for DIC show abnormalities in a. liver function tests. b. tests for renal function. c. platelet counts. d. blood glucose levels.

ANS: C Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of DIC.

23. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels

ANS: C Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of disseminated intravascular coagulation (DIC). DIC does not affect serum glucose levels. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 833 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

14. A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intraaortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)

ANS: C Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an intraaortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis are not indicated in this situation. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

25. One theory suggests that organ dysfunction in MODS occurs in a sequential or progressive pattern. Place the following organs in the order in which they are affected: 1. Bone marrow 2. Cardiac 3. Gut 4. Kidneys 5. Liver 6. Lungs a. 6, 5, 2, 1, 3, 4 b. 5, 4, 6, 1, 2, 3 c. 6, 5, 3, 4, 2, 1 d. 6, 3, 4, 5, 2, 1

ANS: C Organ dysfunction may occur in a sequential or progressive pattern. Organ dysfunction may begin in the lungs, the most commonly affected major organ, and progress to the liver, gut, and kidneys. Cardiac and bone marrow dysfunction may follow. Neurologic and autonomic system impairment may occur and propagate the progression of organ failure, which is associated with illness severity and mortality. Organs may fail simultaneously; for example, kidney dysfunction may occur concurrently with hepatic dysfunction. After the initial insult and resuscitation, patients develop persistent hypermetabolism, a metabolic consequence of sustained systemic inflammation and physiologic stress followed closely by pulmonary dysfunction, manifested as acute respiratory distress syndrome.

6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Check stools for occult blood. d. Palpate for abdominal tenderness.

ANS: C Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

21. A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

ANS: C The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

18. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. obtain the blood pressure. b. check the level of orientation. c. administer supplemental oxygen. d. obtain a 12-lead electrocardiogram.

ANS: C The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.

25. After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment • Petechiae noted on chest and legs • Crackles heard bilaterally in lung bases • No redness or swelling at central line IV site Laboratory Data • Blood urea nitrogen (BUN) 34 mg/Dl • Hematocrit 30% • Platelets 50,000/µL Vital Signs • Temperature 100°F (37.8°C) • Pulse 102/min • Respirations 26/min • BP 110/60 mm Hg • O2 saturation 93% on 2L O2 via nasal cannula a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate.

ANS: C The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.

19. The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury? a. Arachidonic acid metabolite b. Platelet-activating factor c. Tumor necrosis factor d. Interleukin

ANS: C Tumor necrosis factor-á (TNF-á, also known as cachectin) is a polypeptide that is released from macrophages and lymphocytes in response to endotoxin, tissue injury, viral agents, and interleukins. When present in excessive amounts, TNF-á causes widespread destruction in most organ systems and is responsible for the pathophysiologic changes in systemic inflammatory response syndrome (SIRS) and septic shock, including fever, hypotension, decreased organ perfusion, and increased capillary permeability. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 830 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

12. A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure of 92/40 mm Hg

ANS: C Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

16. When SIRS is the result of infection, it is called a. inflammation. b. anaphylaxis. c. sepsis. d. pneumonia.

ANS: C When SIRS is the result of infection, the term sepsis is used.

5. After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. furosemide . b. nitroglycerin . c. norepinephrine . d. sodium nitroprusside .

ANS: C When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

17. The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS)

ANS: C When systemic inflammatory response syndrome (SIRS) is the result of infection, it is referred to as sepsis. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 824 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

20. A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes b. Lack of food ingestion leads to intestinal hypomotility c. Hypoperfusion results in loss of gut barrier function d. Low cardiac output causes decreased hydrochloric acid secretion

ANS: C With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and multiple-organ dysfunction syndrome (MODS). PTS: 1 DIF: Cognitive Level: Understanding REF: p. 830 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

8. The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain a. a dopamine infusion. b. a hypothermia blanket. c. lactated Ringer's solution. d. two 16-gauge IV catheters.

ANS: D A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

5. Which of the following hemodynamic parameters supports the diagnosis of cardiogenic shock? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index

ANS: D Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2.

5. The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index

ANS: D Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

13. Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

13. Which medications are not effective in the immediate treatment of acute anaphylaxis? a. Epinephrine b. Vasopressors c. Diphenhydramine (Benadryl) IV d. Corticosteroids

ANS: D Epinephrine is the first-line treatment of choice for anaphylaxis and should be administered when initial signs and symptoms occur. Several medications are used as second-line adjunctive therapy. Inhaled -adrenergic agents are used to treat bronchospasm unresponsive to epinephrine. Diphenhydramine (Benadryl) given 1 to 2 mg/kg (25?0-50 mg) by a slow intravenous line is used to block histamine response. Ranitidine, given in conjunction with diphenhydramine at a dose of 1 mg/kg intravenously over 10 to 15 minutes, has been found helpful. Corticosteroids are not effective in the immediate treatment of acute anaphylaxis but may be given with the goal of preventing a prolonged or delayed reaction.