MODS, SHOCK, Sepsis, Chapter 66

Which statement describes the reason amlodipine may be used to treat a patient with multiple organ dysfunction syndrome (MODS) who exhibits acute changes in their neurologic status? "Amlodipine is being used to reduce cerebral vasospasm." "The amlodipine is being used to treat low BP." "Amlodipine is the drug of choice to increase oxygen delivery to the other organs." "The amlodipine will help to decrease the need for oxygen."

"Amlodipine is being used to reduce cerebral vasospasm." Rationale Calcium channel blockers like amlodipine are used to reduce cerebral vasospasm in patients with MODS. They block uptake of calcium into the myocardium resulting in vasodilation. Amlodipine does not increase BP; it decreases BP. Amlodipine can increase oxygen delivery to cardiac and other muscles and decrease the need for oxygen, but that is not the indicated use in MODS. pp. 1584-1585

Which actions would the nurse take to optimize tissue oxygenation in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply. -Avoid giving analgesics. -Advise the patient to rest. -Administer sedatives to the patient. -Perform all activities at a particular time of the day. -Frequently reposition the patient for ulcer prophylaxis.

-Advise the patient to rest. -Administer sedatives to the patient. Rationale The patient with SIRS and MODS should be restricted to very limited activity to maintain tissue oxygenation. Resting reduces the body's oxygen demand. Hence, the patient should rest. Sedation is used to help the patient to rest. Analgesics should be given to reduce pain and thereby reduce the demand for oxygen. The nurse should provide care at intervals to reduce the patient's oxygen demand, not at a particular time of the day. The patient should not be repositioned frequently because this may increase oxygen demand on the body.

A patient in a state of shock, is found to be cyanotic and has crackles noted upon auscultation of the lungs. Which type of shock would the nurse expect to incorporate into the patient's plan of care? -Neurogenic -Cardiogenic -Hypovolemic -Anaphylactic

-Cardiogenic Rationale A patient with cardiogenic shock shows peripheral hypoperfusion presenting as cyanosis and has crackles on auscultation of the lungs due to pulmonary congestion. In neurogenic shock, the patient demonstrates symptoms related to the injury such as hypotension and bradycardia. The patient in hypovolemic shock may experience tachycardia as a late sign. In anaphylactic shock, the patient may experience wheezing and stridor.

A nurse is caring for a patient diagnosed with septic shock. Which sign of peripheral hypoperfusion would the nurse assess for in the patient? -Diaphoresis -Dry skin -Redness of the skin -Strong peripheral pulses

-Diaphoresis Rationale One sigh of peripheral hypoperfusion is diaphoresis. Because the patient will sweat, warm, dry skin does not indicate peripheral hypoperfusion. Rather than red skin, the patient will exhibit pallor and cyanosis with peripheral hypoperfusion. Strong peripheral pulses are not present with peripheral hypoperfusion.

The nurse is teaching a student nurse about the mechanisms that can trigger systemic inflammatory response syndrome (SIRS). Which manifestation listed by the student indicates a need for additional instruction? -Burns -Abscess -Pancreatitis -Hypertension

-Hypertension Rationale Hypertension is not a mechanism that triggers SIRS. SIRS is a response to a variety of mechanisms, including burns, abscess, and pancreatitis.

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

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

Which interventions would the nurse incorporate into the plan of care for a patient with multiple organ dysfunction syndrome (MODS) who exhibits signs of cardiovascular dysfunction? Select all that apply. -Providing volume replacement therapy -Decreasing the preload by administering diuretics -Monitoring arterial pressure-based cardiac output (APCO) -Using central venous catheter for hemodynamic monitoring -Maintaining mean arterial pressure at greater than 45 mm Hg

-Providing volume replacement therapy -Monitoring arterial pressure-based cardiac output (APCO) -Using central venous catheter for hemodynamic monitoring Rationale Volume management is done by providing volume replacement therapy in a patient with MODS who also exhibits signs and symptoms of cardiovascular dysfunction. APCO is used for minimally invasive hemodynamic monitoring. A central venous catheter may also be used for hemodynamic monitoring. Volume replacement therapy maintains arterial pressure at greater than 65 mm Hg, not 45 mm Hg, and increases rather than decreases preload.

If the patient in shock is to receive 1000 mL of normal saline in two hours, at which rate would the infusion pump be set? Record your answer using a whole number. 500 mL/hr

500 ml/hr Rationale For the 1000 mL of normal saline to be infused in two hours, the infusion pump should be set at 500 mL per hour (1000 mL divided by two hours).

List the order in which the pathophysiologic steps of systemic inflammatory response syndrome (SIRS) eventually lead to multiple organ dysfunction syndrome (MODS)? Activation of coagulation cascade Formation of microemboli Redistribution of blood flow Compromise of organ perfusion Dysfunction of multiple organs

Activation of coagulation cascade Formation of microemboli Redistribution of blood flow Compromise of organ perfusion Dysfunction of multiple organs Rationale In SIRS, when the mediators and protein leak into the interstitial space, the white blood cells begin to digest foreign bodies. The coagulation cascade is then activated, leading to the formation of microemboli, which results in shunting of blood or redistribution of blood flow. Organ perfusion is compromised, leading to the dysfunction of multiple organs. pp. 1584-1585

Which action would be the priority for a nurse caring for a patient with septic shock who has not responded to fluid resuscitation and has persistent hypotension? Redraw lactic acid. Administer a vasopressor. Insert an indwelling urinary catheter. Obtain a 12-lead echocardiograph (ECG).

Administer a vasopressor. Rationale Patients in septic shock with persistent hypotension who do not respond to fluid resuscitation should be placed on a vasopressor. The physiologic goal is to increase cardiac output and end-organ perfusion. The nurse should redraw the lactic acid, obtain a 12-lead ECG, and insert an indwelling urinary catheter while caring for this patient, but these actions can take place following administration of a vasopressor. p. 1577

Which intervention would the nurse implement for a patient with sepsis who has a temperature of 101.6°F (38.8°C)? Administer antipyretics. Cover the patient adequately. Give the patient a warm bath. Increase the room temperature.

Administer antipyretics. Rationale The nurse should treat the patient's fever with antipyretics and remove the patient's covers or use light sheets. Bathing the patient with warm water will not assist in lowering the patient's core body temperature, and the nurse should decrease the room temperature. p. 1583

A patient with multiple bee stings has edema on the lips and tongue, chest pain, dizziness, wheezing, and stridor. Which type of shock would the nurse expect to incorporate into the plan of care? Septic Obstructive Neurogenic Anaphylactic

Anaphylactic Rationale Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is insect venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Obstructive shock develops when a physical obstruction to blood flow occurs with decreased cardiac output. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above. p. 1569

The nurse assesses a patient with cardiogenic shock and expects which findings? Select all that apply. Anxiety Tachycardia Hypertension Decreased urine output Weak peripheral pulses

Anxiety Tachycardia Decreased urine output Weak peripheral pulses Rationale The early presentation of a patient with cardiogenic shock is similar to that of a patient with acute decompensated heart failure (HF). The patient may have tachycardia. Signs of peripheral hypoperfusion (e.g., cyanosis, pallor, diaphoresis, weak peripheral pulses, cool and clammy skin, delayed capillary refill) occur. Decreased renal blood flow results in sodium and water retention and decreased urine output. Anxiety, confusion, and agitation may develop with impaired cerebral perfusion. The patient may have hypotension, not hypertension. p. 1568

The nurse notes an increase in the depth and rate of the respirations of a patient with septic shock. The nurse suspects which causative factor for the change in the patient's respiratory effort? Loss of blood Increased pain IV fluid overload Attempt to correct metabolic acidosis

Attempt to correct metabolic acidosis Rationale For a patient experiencing septic shock, the respiratory changes in the depth and rate occur as a result of the body's attempt to correct metabolic acidosis. A loss of blood is associated with hemorrhagic shock. The described changes in the respiratory system do not specifically occur as a result of pain. A patient with a fluid overload will have abnormal lung sounds, rapid shallow breathing, and shortness of breath.

Which type of organism most commonly causes sepsis? Fungi Viruses Bacteria Parasites

Bacteria Rationale The most common organisms that cause sepsis are gram-negative and gram- positive bacteria. Fungi, viruses, and parasites can also cause sepsis, but not as frequently.

Which laboratory finding indicates persistent hypermetabolism is occurring in a patient who has developed multiple organ dysfunction syndrome (MODS)? Aspartate aminotransferase (AST) 32 U/L; ALT 20 U/L Blood glucose of 65 mg/dL Blood urea nitrogen (BUN)/creatinine ratio of 19:1 Urine-specific gravity of 1.005

Blood glucose of 65 mg/dL Rationale Normal blood glucose ranges from 70 to 100 mg/dL. Persistent hypermetabolism leads to an inability of the liver to convert lactate to glucose and lactate accumulates. Ultimately, the liver is unable to maintain adequate glucose levels, resulting in hypoglycemia. BUN/creatinine ratio would indicate renal involvement. AST and alanine transaminase (ALT) reflect hepatic involvement. Urine-specific gravity reflects renal involvement. p. 1584

A vasodilator medication is often prescribed for a patient experiencing which type of shock? Septic Neurogenic Cardiogenic Obstructive

Cardiogenic Rationale Vasodilators reduce the cardiac workload, which may be beneficial for the patient in cardiogenic shock. A patient with septic shock requires treatment to increase BP. A vasodilator is not appropriate for the treatment of hypotension and bradycardia, which occurs in a patient with neurogenic shock. A patient with obstructive shock requires the immediate treatment of the cause, and if drug therapy is needed, the patient will receive fluids and drugs to improve blood flow to the organs in the body. p. 1577

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

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

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

Decrease in BP Decrease in mean arterial pressure Decrease in systemic vascular resistance Rationale A patient with SIRS may have cardiovascular system dysfunction manifested as a decrease in BP, mean arterial pressure, and systemic vascular resistance. Heart rate, stroke volume, and cardiac output tend to increase in such patients. p. 1185

Which cardiovascular change is commonly found in patients with systemic inflammatory response syndrome (SIRS)? Decrease in heart rate Decrease in capillary refill Decrease in central venous pressure Decrease in pulmonary artery wedge pressure

Decrease in capillary refill Rationale Patients with SIRS have decreased capillary refill. Other cardiovascular changes include increases rather than decreases in heart rate, central venous pressure, and pulmonary artery wedge pressure.

Which physiologic change is associated with absolute hypovolemia? Third spacing Decreased afterload Absent cardiac output Decreased venous return

Decreased venous return Rationale A decrease in venous return is a physiologic change associated with absolute hypovolemia. Third spacing occurs in relative hypovolemia. The preload, not afterload, and cardiac output are decreased.

Which order would the nurse implement first for a patient showing signs of anaphylactic shock from an insect sting? Diphenhydramine 50 mg IV Oxygen via nasal cannula at 3 L Epinephrine 1:1000, 0.5 mg IM Normal saline IV to run at 150 mL/hr

Epinephrine 1:1000, 0.5 mg IM Rationale The patient experiencing anaphylaxis will have bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. Although administering diphenhydramine, oxygen, normal saline are appropriate, they must be done after an open airway has been established.

Which treatment would the nurse expect to incorporate into the plan of care for a patient who complains of itching, difficulty breathing, and confusion after consuming shellfish? Select all that apply. Famotidine Dobutamine Epinephrine Diphenhydramine Low-molecular-weight heparin

Famotidine Epinephrine Diphenhydramine Rationale Epinephrine is the drug of choice to treat anaphylactic shock. It causes peripheral vasoconstriction and bronchodilation and opposes the effect of histamine. Famotidine is administered to prevent gastrointestinal ulcers and bleeding. IV diphenhydramine is given to block the excessive release of histamine due to an allergic reaction. Dobutamine is given in cases of cardiogenic shock. Low- molecular-weight heparin is usually given in cases of septic shock as a prophylaxis against venous thromboembolism.

Which medication would the nurse prepare to administer to a patient with multiple organ dysfunction syndrome (MODS) who has respiratory, cardiac, and renal involvement? Aldactone Metolazone Furosemide Chlorothiazide

Furosemide Rationale Acute kidney injury is common in patients with MODS. Loop diuretics such as furosemide are used to eliminate water and salt from the body. Aldactone is a potassium-sparing diuretic. Metolazone and chlorothiazide are both thiazide diuretics.

Which clinical manifestation suggests sepsis? Hyperglycemia in the absence of diabetes Sudden diuresis unrelated to drug therapy Respiratory rate of seven breaths per minute Bradycardia with sudden increase in BP

Hyperglycemia in the absence of diabetes Rationale Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis, along with tachypnea and tachycardia, not bradypnea and bradycardia.

Which nursing diagnosis would be the priority for a patient with hypovolemic shock? Acute pain Impaired tissue integrity Decreased cardiac output Ineffective tissue perfusion

Ineffective tissue perfusion Rationale The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output because circulation is a priority. Acute pain may occur but is not a priority at this time. Tissue integrity is not impaired.

Which factors would the nurse consider when administering 5% sodium chloride solution for the initial fluid replacement in a patient with hypovolemic shock? Select all that apply. Monitor the patient for bleeding. Protect the infusion from sunlight. Monitor the patient for renal failure. Infuse the solution through a central line. Monitor the patient closely for signs of hypernatremia.

Infuse the solution through a central line. Monitor the patient closely for signs of hypernatremia. Rationale A 5% sodium chloride solution is a hypertonic solution that is used for initial volume expansion in patients with hypovolemic shock. The patient should be monitored for signs of hypernatremia, such as disorientation and convulsions. The infusion should be administered through a central line because it can damage the peripheral veins. The solution does not increase the risk of bleeding and is not photosensitive. Also, it does not increase the risk of renal failure.

When caring for a patient in acute septic shock, which intervention would the nurse expect to incorporate into the plan of care? Administering osmotic or loop diuretics Administering IV diphenhydramine Infusing large amounts of IV fluids Assisting with insertion of a ventricular assist device (VAD)

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

Which manifestation is a common cause of death for patients with multiple organ dysfunction syndrome (MODS)? Ulcers Sepsis Renal failure Electrolyte imbalances

Sepsis Rationale The mortality rate of patients with MODS is 40% to 60%. The most common cause of death reported is sepsis. Although decreased perfusion increases the risk for ulceration in the gastrointestinal (GI) system, this condition does not usually lead to death. Renal failure requires the use of dialysis until functionality returns or a transplant occurs; this condition does not result in death. Electrolyte imbalances are risk factors of mental status; this condition does not usually cause death. pp. 1584-1585

Which assessment finding indicates cardiovascular dysfunction in a patient with systemic inflammatory response syndrome (SIRS)? Lethargy Skin mottling Cold to the touch Severe dyspnea

Skin mottling Rationale Skin mottling is a sign of cardiovascular dysfunction in a patient with SIRS. This mottling occurs because the patient skin is perfusing, which does not consume much oxygen, while blood is shunted away from other areas. If the patient is lethargic, then the nurse should suspect neurologic dysfunction rather than cardiovascular dysfunction. The nurse should suspect cardiovascular dysfunction if the patient is warm, not cold. Severe dyspnea in a patient with SIRS indicates the development of acute respiratory distress syndrome rather than cardiovascular dysfunction.

Which supportive therapies would a patient admitted with septic shock require? Select all that apply. Stress ulcer prophylaxis Maintaining a patent airway Good blood glucose control Aggressive fluid resuscitation Close temperature monitoring Blood cultures before antibiotics

Stress ulcer prophylaxis Good blood glucose control Aggressive fluid resuscitation Close temperature monitoring Blood cultures before antibiotics Rationale Supportive therapies for patients with septic shock include stress ulcer prophylaxis, good blood glucose control, aggressive fluid resuscitation, close temperature monitoring, and blood cultures before antibiotics. Maintaining an open airway is a supportive therapy for neurogenic and anaphylactic shock.

Which conditions could be the possible causes of obstructive shock? Select all that apply. Spinal cord injury Cardiac tamponade Tension pneumothorax Hypersensitivity to antibiotics Superior vena cava syndrome

Tension pneumothorax Cardiac tamponade vena cava syndrome Rationale Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression caused by cardiac tamponade, tension pneumothorax, or superior vena cava syndrome. Spinal cord injury may lead to neurogenic shock. Hypersensitivity to antibiotics may cause anaphylactic shock.

Which areas would the nurse assess to evaluate end-organ perfusion when caring for a patient who received fluid volume resuscitation for septic shock? Select all that apply. Visual acuity Oral mucosa Urine output Bowel sounds Peripheral pulses Neurologic function

Urine output Peripheral pulses Neurologic function Rationale The goal for fluid resuscitation is restoration of tissue and end-organ perfusion. An assessment of end-organ perfusion includes urine output, peripheral pulses, and neurologic function. Visual acuity, oral mucosa, and bowel sounds do not provide relevant data for the nurse to evaluate end-organ function. p. 1576

Which nursing interventions would be utilized in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply. -Avoiding multiple venipunctures -Minimizing IM injections -Infusing insulin and glucose continuously -Ensuring continuous echocardiographic monitoring -Providing positive end-expiratory pressure ventilation

-Avoiding multiple venipunctures -Minimizing IM injections Rationale Platelet count is decreased in patients with SIRS and MODS with hematologic dysfunction. This decrease increases the risk for bleeding. Therefore multiple venipunctures should be avoided, and IM injections should be minimized to decrease traumatic interventions. Continuous infusion of insulin and glucose may be needed to maintain blood glucose levels in cases in which there is endocrine dysfunction rather than hematologic dysfunction. Continuous echocardiographic monitoring helps to manage cardiovascular dysfunctions rather than hematologic dysfunctions. Positive end-expiratory pressure ventilation helps to manage respiratory dysfunction associated with SIRS and MODS. pp. 1584-1585

The nurse suspects that a patient with septic shock has developed acute respiratory distress syndrome (ARDS). Which intervention is the nurse's priority? Repeat chest radiograph. Draw arterial blood gasses. Start broad-spectrum antibiotics. Begin pulmonary management with mechanical ventilation.

-Begin pulmonary management with mechanical ventilation. Rationale Patients with ARDS need aggressive pulmonary management with mechanical ventilation. Repeating chest radiograph may be done after initiation of mechanical ventilation. Arterial blood gas measures respiratory alkalosis in early stages of septic shock and metabolic acidosis in late stages of septic shock. Broad-spectrum antibiotics are important in the early component of therapy and should be started within the first hour of severe sepsis or septic shock, but once breathing is compromised, that becomes the priority.

When considering the use of nitroglycerin for treating a patient with shock, which actions would the nurse perform? Select all that apply. -Monitor the heart rate. -Monitor the BP. -Use a glass bottle for infusion -Protect the solution from sunlight. -Administer the solution through a central line.

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

Which sign would the nurse monitor for in a patient with neurogenic shock receiving phenylephrine? -Dyspnea -Hypokalemia -Reflex bradycardia -Hypothyroidism

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

A patient is newly admitted to an intensive care unit (ICU) with septic shock. The nurse anticipates which type of enteral nutritional therapy? -The calories will be adjusted based on daily weights. -The patient will be started on a small amount of nutrition (10 mL/hr). -The patient will be started on feedings after the condition stabilizes. -The total albumin is used to determine the patient's nutritional status.

-The patient will be started on a small amount of nutrition (10 mL/hr). Rationale Patients are started on a trophic feeding, which is a small amount of enteral nutrition. Daily weights are a better indicator of fluid status than caloric needs due to the third spacing of fluids. Eternal nutrition should be started within the first 24 hours due to the hypermetabolic state of the patient. Serum protein, total albumin, prealbumin, blood urea nitrogen (BUN), serum glucose, and serum electrolytes are all used to assess nutritional status.

Which oxygen-delivery measures would the nurse incorporate into the plan of care for a patient in shock? Select all that apply. Administer supplemental oxygen as prescribed. Space activities that increase oxygen consumption. Space activities that decrease oxygen consumption. Monitor continuously by using a central venous catheter. Encourage the patient to move around to increase lung expansion.

Administer supplemental oxygen as prescribed. Space activities that increase oxygen consumption. Monitor continuously by using a central venous catheter. Rationale To optimize oxygen supply and ventilation in a patient suffering from shock, the activities that increase oxygen consumption should be evenly spaced. Mixed venous oxygen saturation should be monitored through a central venous catheter. The patient should not exert energy by excessive moving around because it increases oxygen demand. p. 1575

Which clinical manifestation warns the nurse that a patient's condition is progressing to multiple organ dysfunction syndrome (MODS)? Hypotension and dysrhythmias Urine output less than 400 mL/day Alteration in level of consciousness Decreased PaO 2 with an increase in FiO 2

Decreased PaO 2 with an increase in FiO 2 Rationale. Decreased PaO 2 with an increase in FiO 2 (refractory hypoxemia) is the correct answer because the lungs are the first organ to show signs of dysfunction and are the main organ affected in multiple organ dysfunction syndrome. Hypotension and dysrhythmias can occur with hypovolemia and hypoxia without progressing to multiple organ dysfunction syndrome. Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome when the kidneys become involved. Alteration in level of consciousness is probably already present with the closed head injury, and also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia, and will not necessarily progress to MODS.

Which medication would the nurse expect to incorporate into the plan of care to manage cardiac manifestations of multiple organ dysfunction syndrome (MODS)? Digoxin Lisinopril Metoprolol Dobutamine

Dobutamine Rationale Vasopressors are used to address issues related to the cardiovascular system in MODS. Dobutamine is a vasopressor that directly stimulates β-1 receptors of the heart to increase myocardial contractility and stroke volume and is used to address cardiac manifestations. Digoxin is a cardiac glycoside. Lisinopril is an angiotensin- converting enzyme (ACE) inhibitor. Metoprolol is a β-blocker.

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

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

Which type of shock causes an absence of bowel sounds? Neurogenic Cardiogenic Hypovolemic Anaphylactic

Hypovolemic Rationale Absence of bowel sounds is associated with hypovolemic shock. Decreased bowel sounds are seen with cardiogenic shock. Bowel dysfunction is associated with neurogenic shock. Abdominal pain, nausea, and vomiting are seen with anaphylactic shock.

Which laboratory findings of a patient with systemic inflammatory response syndrome (SIRS) suggest progression to hepatic dysfunction? Select all that apply. Bilirubin 30 μmol/L Urine Na + 24 mEq/L Increase in serum ammonia Decrease in serum transferrin Ventilation-perfusion (V/Q) mismatch

Increase in serum ammonia Decrease in serum transferrin Rationale Loss of liver function leads to the accumulation of waste products such as ammonia. Hence, an increase in the serum ammonia level indicates hepatic dysfunction. In patients with SIRS, the plasma transferrin level helps to assess protein synthesis. When hepatic dysfunction occurs, there is a decrease in serum transferrin. In hepatic dysfunction, there is accumulation of bilirubin. A bilirubin level greater than 34 μmol/L suggests hepatic dysfunction. A urine NA + level of 24 mEq/L indicates acute tubular necrosis or an intrarenal manifestation of renal system dysfunction. It does not indicate hepatic dysfunction. Ventilation-perfusion (V/Q) mismatch suggests development of acute respiratory distress syndrome (ARDS) rather than hepatic dysfunction. p. 1585

Which therapy would the nurse incorporate into the plan of care for a patient with acute respiratory distress syndrome (ARDS)? Mechanical ventilation Oxygen via a Venturi mask Oxygen via a non-rebreather mask Small volume nebulizer treatments

Mechanical ventilation Rationale A patient with ARDS would be intubated and receive mechanical ventilation. Small volume nebulizer treatments would open airways; however, this intervention will not sufficiently treat ARDS. Oxygen via a Venturi mask or a non-rebreather mask would be insufficient to promote oxygenation and perfusion. p. 1584

Which medical diagnosis would the nurse suspect as the cause of cardiogenic shock? Urosepsis Hemorrhage Myocardial infarction Tension pneumothorax

Myocardial infarction Rationale Myocardial infarction may produce necrotic areas of cardiac tissue that lead to impaired contractility and decreased cardiac output. This may lead to a cardiogenic shock state. Hemorrhage may lead to a hypovolemic shock state, tension pneumothorax may lead to an obstructive shock state, and urosepsis may lead to a septic shock state. p. 1570

Which type of shock is associated with bradycardia? Septic Neurogenic Anaphylactic Hypovolemic

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

Which patient would the nurse suspect may have multiple organ dysfunction syndrome (MODS)? Patient A Patient B Patient C Patient D

Patient A (has) -Burns over 30% of Toal body surface area -BUN/creatine ratio 24:1 specific gravity 1.032 -Dyspnea, tachypnea, PAWP 14 mm Hg Rationale MODS requires involvement of at least two organ systems. Patient A has a blood urea nitrogen (BUN)/creatinine ratio greater than 20:1 and a urine specific gravity greater than 1.020, which indicates renal involvement; dyspnea, tachypnea, and a pulmonary arterial wedge pressure (PAWP) less than 18 mm Hg indicate respiratory involvement, thus supporting a potential diagnosis of MODS. Patient B has symptomology indicating involvement of only the hepatic system; the alanine transaminase (ALT) (normal 10 to 40 U/L) and aspartate aminotransferase (AST) (normal 10 to 30 U/L) are both elevated and the patient has jaundice. The urine-specific gravity is less than 1.020 (greater than 1.020 indicates renal hypoperfusion) and BP are within normal limits. Patient C's blood glucose is within normal limits (70 to 120 mg/dL), but urine- specific gravity is elevated, and the urine is dark, indicating possible involvement of only one system (renal). Patient D has a decreased Hct (normal Hct 39% to 50% for males and 35% to 47% for females) and a decreased red blood cell (RBC) count; normal values range from 3.8/4.3 to 5.1/5.7 x 10 6/μL (male/female) and a decreased Hgb (normal Hgb 13.2 to 17.3 g/dL for males and 11.7 to 15.5 g/dL for females, which may indicate blood loss but does not support a diagnosis of MODS.

A patient diagnosed with septic shock receives aggressive fluid resuscitation. The nurse performs a passive leg raise challenge to assess which process? Organ perfusion Tissue perfusion Mean arterial pressure Patient responsiveness to fluids

Patient responsiveness to fluids Rationale Performing a passive leg raise provides the nurse with an indication of patient responsiveness to fluids. If the passive leg raise is positive, then the patient is fluid-responsive and should receive additional fluids. If the passive leg raise is negative, then the patient is not fluid-responsive, and a vasopressor should be started. The passive leg raise does not provide information about organ perfusion, tissue perfusion, and mean arterial pressure. p. 1579

The nurse provides care for a patient experiencing shock. Assessment findings are indicative of decreasing cardiac output and decreased peripheral perfusion. The nurse identifies that the patient is in which stage of shock? Initial Refractory Progressive Compensatory

Progressive Rationale The cardiovascular system is profoundly affected in the progressive stage of shock. Manifestations of the progressive stage of shock include decreased cardiac output, which leads to decreased BP and increased heart rate (HR). Other manifestations include decreased peripheral perfusion, which leads to ischemia of distal extremities, decreased pulses, and decreased capillary refill. The initial stage of shock is usually not accompanied by clinical changes. During the refractory stage, decreasing coronary blood flow continues to occur, which leads to worsening myocardial depression. During the compensatory phase, coronary arterial dilation occurs, resulting in improved blood flow to the heart. p. 1574

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

Refractory hypoxemia Rationale In a patient with SIRS, refractory hypoxemia suggests respiratory system dysfunction. Other manifestations of respiratory system dysfunction include pulmonary hypertension, decreased compliance, and increased minute ventilation. p. 1585

Which process occurs when the inflammatory response is activated in a patient with systemic inflammatory response syndrome (SIRS)? Release of mediators Decrease in metabolism Damage of the mesothelium Decrease in vascular permeability

Release of mediators Rationale A release of mediators occurs when the inflammatory response is activated. Other changes that occur include an increase in metabolism or hypermetabolism, direct damage to the endothelium (not mesothelium), and an increase in vascular permeability. p. 1584

Which organ system is often the first to show signs and symptoms in multiple organ dysfunction syndrome (MODS)? Neurologic Respiratory Cardiovascular Gastrointestinal

Respiratory Rationale Inflammatory mediators have a direct effect on the pulmonary vasculature, causing increased capillary permeability and eventually movement of fluid into the interstitial spaces of the lungs, eventually causing alveolar edema, often making the respiratory system the first to show signs and symptoms of MODS. While MODS affects the neurologic, cardiovascular, and gastrointestinal systems as well, these systems do not as commonly exhibit manifestations of MODS first.

Which arterial blood gas finding is associated with a patient experiencing early shock? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory alkalosis Rationale Respiratory alkalosis is associated with early signs of shock as a result of hyperventilation. Metabolic acidosis and alkalosis, or respiratory acidosis, are not arterial blood gas findings related to early shock.

A patient with pneumonia develops hypotension, hypothermia, leukocytosis, and hypoxemia. Which type of shock would the nurse infer from these findings? Septic Neurogenic Cardiogenic Hypovolemic

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

Which term is used to describe persistent hypotension despite adequate fluid resuscitation requiring vasopressors along with inadequate tissue perfusion resulting in tissue hypoxia? Sepsis Septic shock Inflammation Organ dysfunction

Septic shock Rationale Septic shock is characterized by persistent hypotension despite adequate fluid resuscitation requiring vasopressors along with inadequate tissue perfusion resulting in tissue hypoxia. Sepsis is a constellation of symptoms or a syndrome in response to an infection; it is characterized by a dysregulated patient response. Inflammation is the body's response to a microorganism. Organ dysfunction refers to the failure of an organ system in an acutely ill patient such that homeostasis cannot be maintained without intervention.

The nurse is caring for a patient who has hypovolemic shock. Which condition would the nurse expect to incorporate into the plan of care? Insect bite Severe burns Myocardial infarction Pulmonary embolism

Severe burns Rationale Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. Insect bites may lead to an anaphylactic shock state. Pulmonary embolism may lead to an obstructive shock state, and myocardial infarction may lead to a cardiogenic shock state. p. 1570

The nurse anticipates which clinical findings in a patient who presents with anaphylactic shock? Select all that apply. Stridor Pruritus Anxiety Pallor Chest pain

Stridor Pruritus Anxiety Chest pain Rationale Clinical findings associated with anaphylactic shock include stridor, pruritus, anxiety, and chest pain. The patient will experience skin flushing, not pallor. p. 1569

The nurse is teaching a student nurse about treatment for sepsis. Which response by the student indicates a need for further teaching? "We should provide broad-spectrum antibiotics." -"Antibiotics should be administered in one hour." -"Blood cultures must be drawn before the administration of antibiotics." -"Antibiotics should be delayed until the causative organism is known."

-"Antibiotics should be delayed until the causative organism is known." Rationale More specific antibiotics may be ordered once the organism has been identified, but administration of antibiotics should not be delayed. Broad-spectrum antibiotics are given first. Antibiotics are an important early component of therapy and should be started in the first hour. The nurse should obtain blood cultures before antibiotics are started. p. 1579

The family of a patient being treated for multiple organ dysfunction syndrome (MODS) asks the nurse why the patient is being sedated and placed on mechanical ventilation. Which explanation by the nurse is correct? -"This allows the gastrointestinal system to rest, which helps prevent hyperglycemia." -"All patients with MODS are sedated and placed on mechanical ventilation as a preventive measure." -"Sedation and mechanical ventilation help to decrease oxygen demands and increase oxygen delivery to organs. -"Sedation and mechanical ventilation help to keep the patient from having a heart attack, which is common with MODS."

-"Sedation and mechanical ventilation help to decrease oxygen demands and increase oxygen delivery to organs. Rationale Hypoxemia is common in MODS; sedation and mechanical ventilation help to decrease oxygen demands and maintain adequate oxygen delivery to organs. While decreasing oxygen demands may help to prevent the failure of other systems, it does not necessarily allow the gastrointestinal system to rest. Not all patients with MODS require sedation and mechanical ventilation. Sedation and mechanical ventilation do not necessarily prevent heart attacks. pp. 1584-1585

A nurse is teaching a student nurse about multiple organ dysfunction syndrome (MODS). Which statement by the student indicates correct understanding of the concept? -"Metabolic changes such as hypermetabolism in MODS are short-lived and self-limiting." -"Evidence of liver dysfunction can be noted fairly early due to changes in liver enzyme levels." -"When systemic inflammatory response syndrome (SIRS) progresses to MODS, mortality rates increase a bit but are still 80% to 90%." -"We would generally see dyspnea, changes in pulmonary artery wedge pressure (PAWP), tachypnea, and a decreasing PaO 2/FIO ratio as early signs."

-"We would generally see dyspnea, changes in pulmonary artery wedge pressure (PAWP), tachypnea, and a decreasing PaO 2/FIO ratio as early signs." Rationale The respiratory system is generally the first to show signs of dysfunction in MODS, which means that dyspnea and tachypnea changes in PAWP and a decreasing PaO 2/FIO ratio may be early indicators. Metabolic changes are not self-limiting because they can trigger a hypermetabolic response and last for several days. Liver dysfunction often begins long before clinical evidence of the dysfunction is apparent. Prognosis once MODS develops is poor, with a 40% to 60% mortality rate. pp. 1584-1585

Which patient would the nurse monitor most closely for possible development of sepsis? -A seven-year-old patient with ear pain and history of chronic otitis media -An 86-year-old patient with a fever and history of chronic urinary tract infections -A 54-year-old patient with a sore throat and no significant previous medical problems -A 62-year-old patient with complaints of cough and history of chronic obstructive pulmonary disease (COPD)

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

Which clinical manifestations would the nurse expect to find when assessing a patient in hypovolemic shock? Select all that apply. -Anxiety -Tachycardia -Hypotension -Hypothermia -Lactic acidosis -Decreased capillary refill

-Anxiety -Tachycardia -Hypotension -Decreased capillary refill Rationale In a patient with hypovolemic shock due to hemorrhage, assessment findings will be related to intravascular fluid loss that include cool skin, decreased capillary refill, hypotension, orthostatic changes, tachycardia, anxiety, and decreased urine output. Measure cardiac output. https://eaqng.elsevier.com/#/quizPerformance/20081596 Page 3 of 41 Elsevier Adaptive Quizzing - Quiz performance 9/20/21, 11:07 AM Hypothermia is associated with spinal cord injury. Lactate, not lactic acid, is increased. p. 1570

A patient with multiple organ dysfunction syndrome (MODS) has not responded to treatment despite the use of mechanical ventilation, sedation, nutritional, and cardiac support. Which option would the nurse anticipate being discussed with the patient's family? -Discuss life support withdrawal and initiation of end-of-life care. -Transfer to a long-term acute care facility for more intensive care and support. -Consult requests for primary care providers with expertise in multiple organ failure. -Test to determine whether the patient meets the clinical and legal criteria for brain death.

-Discuss life support withdrawal and initiation of end-of-life care. Rationale If a patient is not responding to treatment efforts, then the health care team and the patient's family will need to discuss realistic goals and options, such as withdrawal of life support and end-of-life care. Transfer to a different facility will not change the probable outcome. A patient who has not responded to treatment for MODS would not be helped by additional consults. Determining whether the patient meets the legal criteria for brain death may occur but would not be the next option. p. 1586

Which interventions would the nurse expect to incorporate into the plan of care to prevent health care-associated infections for a patient with multiple organ dysfunction syndrome (MODS)? Select all that apply. -Daily arterial blood gases (ABGs) -Early surgery to remove necrotic tissue -Ambulating patient as early as possible -Daily assessment of continuing need for invasive lines and devices -Strict use of aseptic and sterile technique in relation to lines and tubes

-Early surgery to remove necrotic tissue -Ambulating patient as early as possible -Daily assessment of continuing need for invasive lines and devices -Strict use of aseptic and sterile technique in relation to lines and tubes Rationale Prevention of health care-associated infections is a priority for the care of a patient suffering from MODS. Removing necrotic tissue removes a possible medium for microorganisms. Early mobilization aids in pulmonary management to decrease the risk for infection. Assessing for the need for ongoing invasive lines and devices allows these to be discontinued when no longer needed to decrease entry routes for infection. Strict use of aseptic and sterile technique as indicated helps to decrease the possibility of infection. Daily ABGs may be indicated with MODS, but obtaining these does not directly address the risk for infection.

When examining a patient in the progressive stage of shock, which factors related to the gastrointestinal (GI) system would the nurse consider the patient to be at an increased risk for developing? Select all that apply. -GI bleeding -GI ulcers -Motility issues -Nutrient absorption issues -Bacterial migration from the GI tract to the bloodstream.

-GI bleeding -GI ulcers -Motility issues -Nutrient absorption issues -Bacterial migration from the GI tract to the bloodstream. Rationale In the progressive stage of shock, the GI system gets affected by prolonged decreased tissue perfusion. As the blood supply to the GI tract is decreased, the normally protective mucosal barrier becomes ischemic. This ischemia predisposes the patient to ulcers and GI bleeding. It also increases the risk of bacterial migration from the GI tract to the blood. The decreased perfusion to the GI tract also results in a decreased ability to absorb nutrients, decreased motility, and slowed peristalsis. p. 1570

Which complication would the nurse monitor for in a patient with sepsis who received large amounts of fluid resuscitation in the emergency room? -Hypothermia -Hypokalemia -Reflex bradycardia -Cardiac stimulation

-Hypothermia Rationale When large amounts of fluid are required, the nurse must assess the patient for two major complications: hypothermia and coagulopathy. Hypokalemia and hyperglycemia must be assessed when patients receive hydrocortisone. Reflex bradycardia and headache are side effects of phenylephrine. Cardiac stimulation and bronchodilation are intentionally induced with the use of epinephrine in anaphylactic shock.

Which signs and symptoms would alert the nurse to the presence of multiple organ dysfunction syndrome (MODS)? Select all that apply. -Lethargy -Confusion -Pulse of 112 beats/min -Respiratory rate of 32 breaths/min -BP of 80/60 mm Hg -Purulent drainage from a wound

-Lethargy -Confusion -Pulse of 112 beats/min -BP of 80/60 mm Hg Rationale Lethargy and confusion indicates neurologic dysfunction, while tachycardia, tachypnea, and hypotension characterize respiratory and cardiac manifestations of MODS. Wound drainage characterizes signs of an infection, which could be related to the development of MODS but is not diagnostic of MODS. p. 1585

An increase in which hepatic parameters would the nurse likely find in the laboratory report of a patient with multiple organ dysfunction syndrome (MODS)? Select all that apply. -Liver enzymes -Serum albumin - Ammonia (NH 3) -Serum transferrin -Bilirubin greater than 2 mg/dL

-Liver enzymes - Ammonia (NH 3) -Bilirubin greater than 2 mg/dl Rationale The patient with MODS has compromised hepatic function manifested by increased ammonia, bilirubin levels greater than 2 mg/dL, and increased liver enzymes. Hepatic hypoperfusion and the resultant cell damage may result in decreased serum albumin and transferrin.

The nurse would evaluate which response to determine the effectiveness of the use of vasopressor in a patient with sepsis? -SpO 2 greater than 94% -Lactic acid less than 2.0 mmol/L -Mean arterial pressure greater than 65 mm Hg -Systolic BP greater than 80 mm Hg

-Mean arterial pressure greater than 65 mm Hg Rationale The goal of vasopressor therapy is to maintain a mean arterial pressure greater than 65 mm Hg. Fluids can be increased or vasopressor therapy can be decreased if the patient develops hypotension. Vasopressors do not have an effect on lactic acid results or SpO 2.

When using dextran as a fluid therapy for a patient who is in a state of shock, which factors would the nurse consider? Select all that apply. -Monitor for allergic reactions. -Dextran as a fluid therapy increases the risk of bleeding. -Use may increase oxygen carrying capability of the blood. -Use in limited quantities for shock therapy because it has side effects. -It helps to control bleeding caused by thrombocytopenia.

-Monitor for allergic reactions. -Dextran as a fluid therapy increases the risk of bleeding. -Use in limited quantities for shock therapy because it has side effects. Rationale It is important to monitor the patient for allergic reactions and acute renal failure because dextran is often associated with side effects and allergic reactions. The use of dextran as a fluid therapy increases the risk of bleeding, and, therefore, it has limited use in shock therapy. Dextran is a hyperosmotic glucose polymer, and it does not increase the oxygen-carrying capability of blood or help to control bleeding caused by thrombocytopenia.

Which interventions would the nurse implement when administering isotonic fluid replacement for a patient in shock? Select all that apply. -Monitor the patient for hypernatremia. -Monitor the patient for hypersensitivity reactions. -Administer the infusion only through a central line. -Monitor the patient closely for circulatory overload. -Avoid using lactated Ringer's solution in patients with liver failure.

-Monitor the patient closely for circulatory overload. -Avoid using lactated Ringer's solution in patients with liver failure. Rationale Isotonic fluids primarily remain in the intravascular space and increase the intravascular volume. Therefore, the patient should be closely monitored for circulatory overload. Use of lactated Ringer's solution should be avoided in patients with liver failure because it results in the accumulation of lactate. The isotonic fluids do not cause hypernatremia or hypersensitivity reactions. These solutions do not damage the peripheral veins and can be safely administered through peripheral lines. A central line is not required.

Which strategies would the nurse implement to reduce the risk for sepsis in a patient who is immunocompromised? Select all that apply. -Change the IV site daily. -Administer antibiotics prophylactically. -Pay strict attention to thorough hand washing. -Use aseptic technique during invasive procedures. -Thoroughly clean or discard equipment between patients.

-Pay strict attention to thorough hand washing. -Use aseptic technique during invasive procedures. -Thoroughly clean or discard equipment between patients. Rationale Patients who are immunocompromised are at a high risk for opportunistic infection. Strategies to decrease the risk for infection include paying attention to strict hand washing, using aseptic technique during invasive procedures, and thoroughly cleaning or discarding equipment between patients. Changing the IV site daily increases the risk for infection. Antibiotics are not administered prophylactically.

Which intervention would the nurse expect to incorporate into the plan of care for a patient receiving ventilation support for multiple organ dysfunction syndrome (MODS) to reduce the chance for respiratory complications? -Turn the patient from side to side every two hours. -Increase IV fluids to 3000 mL/24 hours. -Place the patient in a continuous-motion bed frame. -Administer breathing treatments every two hours.

-Place the patient in a continuous-motion bed frame. Rationale Continuous lateral rotation therapy via a continuous-motion bed frame is used to increase mobilization and prevent nosocomial infections in the ventilated patient. Turning the patient every two hours can also be helpful, but this is not as effective as continuous lateral rotation therapy. Increasing fluids to 3000 mL may lead to other complications and is not the best choice in this situation. While breathing treatments can also be helpful, continuous lateral rotation therapy is the most effective choice. p. 1585

Which findings indicate the development of acute respiratory distress syndrome (ARDS) in a patient with systemic inflammatory response syndrome (SIRS)? Select all that apply. Pulmonary hypertension Decreased lung compliance Decreased minute ventilation Abnormally slow breathing rate Bilateral diffuse infiltrates in the chest

-Pulmonary hypertension -Decreased lung compliance -Bilateral diffuse infiltrates in the chest Rationale In patients with SIRS, the inflammatory mediators leading to pulmonary hypertension directly affect the pulmonary vasculature. The patient with ARDS shows decreased compliance due to the combined effects of pulmonary vasoconstriction and bronchoconstriction. There are bilateral diffuse fluffy infiltrates seen on the chest

Which action would the nurse take when administering packed red blood cells (RBCs) to a patient in hypovolemic shock? -Warm the pack before administering. -Check the patient's hypersensitivity to the product. -Provide antibiotics based on the clinical condition. -Replace clotting factors based on laboratory studies.

-Replace clotting factors based on laboratory studies. Rationale When administering large volumes of packed RBCs, it is important to replace clotting factors to prevent coagulopathy. Because the pack contains only RBCs and not the clotting factors, it should be given extrinsically. Generally, the crystalloid and colloid solutions are warmed before being administered to avoid hypothermia. However, packed RBCs should not be warmed because high temperature can damage the red blood cells. The blood products are almost always cross typed and matched before administration. Antibiotics are not related to the administration of RBC's.

Which interventions would the nurse expect to incorporate into the plan of care for a patient with multiple organ dysfunction syndrome (MODS) to help to decrease oxygen demand? Select all that apply -Sedate the patient. -Administer analgesics. -Catheterize the patient. -Initiate mechanical ventilation. -Assist the patient to move around.

-Sedate the patient. -Administer analgesics. -Initiate mechanical ventilation. Rationale When managing hypoxemia in a patient with MODS, decreasing the oxygen demand is very important for adequate tissue oxygenation. Sedation, providing analgesia, and mechanical ventilation are helpful in decreasing the oxygen demand of the tissues. Catheterizing the patient may aid in monitoring the urine output but does not help to conserve oxygen. Resting the patient should be preferred over ambulation or movement to limit the intake of oxygen.

When managing a patient with shock, which actions would the nurse take as part of nutritional therapy? Select all that apply. -Start enteral nutrition within the first 24 hours. -Wait until the patient recovers to start with enteral nutrition. -Start a slow continuous drip of small amounts of enteral feedings. -Plan enteral feeding to meet at least 50% of calorie requirements. -Start parenteral nutrition if enteral feedings are contraindicated.

-Start enteral nutrition within the first 24 hours. -Start a slow continuous drip of small amounts of enteral feedings. -Start parenteral nutrition if enteral feedings are contraindicated. Rationale Enteral nutrition should ideally begin within the first 24 hours. It is important because it enhances the perfusion of the gastrointestinal (GI) tract and helps to maintain the integrity of the gastrointestinal mucosa. Enteral feeding should be started with a slow, continuous drip of small amounts of enteral feedings. If enteral feedings are contraindicated, then parenteral feedings can be started. Nutritional therapy should start as early as possible. The nurse should not wait for the patient to recover before starting nutritional therapy. Enteral feeding should be planned to meet at least 80% of the total calorie requirements, but if it is not feasible, parenteral feeding should be started. pp. 1577-1578

The nurse reviews the plan of care for a patient with multiple organ dysfunction syndrome (MODS). Which outcome would be desirable for this patient? -The patient will be free of signs and symptoms of sepsis. -The patient will maintain a balanced fluid intake and output. -The patient will experience enhanced overall well-being and mental rest. -The patient will demonstrate improved perfusion and oxygenation of organs.

-The patient will demonstrate improved perfusion and oxygenation of organs. Rationale The underlying pathophysiology of MODS is a lack of perfusion to organs, resulting in tissue and/or organ hypoxia. Interventions to improve perfusion with fluids or medications improve patient outcomes. The outcomes listed in the other answer options are appropriate and desirable for the patient with MODS, but they are secondary to improved perfusion and oxygenation.

Which factor would the nurse identify as the cause of pulmonary edema in a patient with multiple organ dysfunction syndrome (MODS)? -Tissue hypoxia -Unregulated apoptosis -Microvascular coagulopathy -Uncontrolled systemic inflammation

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

In which order would the nurse complete the steps for a passive leg raise challenge? 1) Lay the patient supine 2) Raise the legs to 45 degrees 3)Measure cardiac output 4) Evaluate the patient hemodynamic improvement

1) Lay the patient supine Rationale When performing a passive leg raise, the patient is placed supine, and the nurse then raises the patient's legs to 45 degrees. The nurse measures responsiveness in one to two minutes by measuring cardiac output. The nurse then evaluates the patient for hemodynamic improvement.

Which actions would the nurse take to safely administer dobutamine to a patient with cardiogenic shock? Select all that apply. Use a glass bottle for infusion. Administer through a central line. Monitor heart rate and BP. Stop infusion if tachydysrhythmias develop. Always administer with sodium bicarbonate.

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

Which medication would the nurse prepare to administer to a patient with septic shock? Insulin infusion Aggressive IV crystalloid fluid resuscitation IV administration of epinephrineA dministration of nitrates and β-adrenergic blockers

Aggressive IV crystalloid fluid resuscitation Rationale Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock. p. 1577

Which action would the nurse take when caring for a patient with multiple organ dysfunction syndrome (MODS)? Avoid giving sedatives. Require bed rest for several weeks. Utilize the parenteral mode for nutrition. Aim for glycemic control at 140 to 180 mg/dL.

Aim for glycemic control at 140 to 180 mg/dL. RationaleWhen caring for a patient with MODS, the nurse should pay attention to the glycemic control with a goal of 140 to 180 mg/dL. The aim of proper nutritional support is to preserve organ function. Sedation may be given to patients with MODS because it helps to decrease the oxygen demand. Patients should not be put on bed rest for several weeks. Early ambulation helps to reduce infections. The enteral mode is the preferred mode of nutrition. However, if it is not possible or it does not meet the caloric needs of the patient, parenteral nutrition should be initiated or added. pp. 1584-1585

The nurse assesses a patient and suspects a diagnosis of neurogenic shock based on which findings? Select all that apply. Dyspnea Bradycardia Weak pulses Hypotension Unstable temperature

Bradycardia Hypotension Unstable temperature Rationale Signs of neurogenic shock include bradycardia, hypotension, and temperature instability. Dyspnea and weak pulses are not signs associated with neurogenic shock. p. 1570

Which medication is used for the management of confusion, disorientation, and delirium in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Vasopressors Loop diuretics Proton pump inhibitors Calcium channel blockers

Calcium channel blockers Rationale Impaired perfusion of the brain may cause confusion, disorientation, and delirium in the patient. The health care provider is likely to prescribe calcium channel blockers to a patient exhibiting confusion, disorientation, and delirium to reduce cerebral vasospasm and improve perfusion of the brain. Vasopressors may be prescribed to combat cardiovascular dysfunction. Loop diuretics are prescribed if there is renal dysfunction. Proton pump inhibitors are prescribed to manage gastrointestinal symptoms. pp. 1584-1585

Which factors that directly affect oxygen delivery would the nurse monitor for in a patient with septic shock? Select all that apply. Urine output Cardiac output White blood cells Available hemoglobin Arterial oxygen saturation

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

Which condition places a patient at risk for obstructive shock? Pneumonia Severe burn Cardiac tamponade Hypersensitivity to a vaccine

Cardiac tamponade Rationale Obstructive shock develops when a physical obstruction to blood flow occurs with a decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression (e.g., cardiac tamponade, tension pneumothorax, superior vena cava syndrome). Septic shock occurs as a result of an infection such as pneumonia. A severe burn can result in fluid loss, causing hypovolemic shock. Anaphylactic shock can result from hypersensitivity to a vaccine.

The nurse provides care for a patient with septic shock. The nurse recalls that the renin-angiotensin system is activated during which stage of shock? Initial Refractory Progressive Compensatory

Compensatory Rationale During the compensatory stage, the body's responses reflect the imbalance in the oxygen supply and demand. Decreased blood flow to the kidneys activates the renin-angiotensin system. Renin stimulates angiotensinogen to make angiotensin I, which is then converted to angiotensin II. Angiotensin II is a potent vasoconstrictor that causes both arterial and venous vasoconstriction. The net result is an increase in venous return to the heart and an increase in BP. During the initial stage of shock, there is no noticeable decrease in urine output because the pathology occurs at a cellular level. Organ failure occurs during the refractory stage, resulting in anuria. During the progressive stage of shock, hypoperfusion of the kidneys occurs, resulting in the abnormal output of urine.

Which manifestations are considered late signs of septic shock? Select all that apply. Cool skin Mottled skin Respiratory alkalosis Altered mental status Myocardial dysfunction

Cool skin Mottled skin Myocardial dysfunction Rationale Late signs of septic shock are cool and mottled skin and myocardial dysfunction. The release of platelet-activating factors increases coagulation, resulting in the formation of microthrombi and decreased blood flow in the microcirculation. The patient in early stages of septic shock may have warm and flushed skin, respiratory alkalosis, altered mental status, and decreased urine output.

Which tests would the nurse expect to be ordered for a patient experiencing shock? Select all that apply. Creatinine Arterial blood gases Complete blood count Glycosated hemoglobin Prostate surface antigen (PSA)

Creatinine Arterial blood gases Complete blood count RationaleCreatinine is a blood test to check kidney function, which is crucial for a patient with shock. Arterial blood gases would be ordered to assess acid-base balance and oxygenation status. A complete blood count would also be ordered to assess red and white blood cell function. PSA is done as a screening for prostate cancer and would not be ordered for a patient experiencing shock. Although a glucose level would need to be checked on a patient in shock, a glycosated hemoglobin assessment, which examines blood glucose control over 12 weeks, would not be ordered for a patient in shock.

Septic shock is classified as which type of shock? Distributive Obstructive Cardiogenic Hypovolemic

Distributive Rationale Septic shock is classified as distributive shock, which is a result of abnormal distribution of blood flow, causing an inadequate supply of blood to meet the metabolic needs of the body's tissue and organs. Septic shock is characterized by hypotension and inadequate tissue perfusion, resulting in inadequate supply of blood to meet the metabolic needs of the body's tissues and organs. Neurogenic shock, anaphylactic shock, and septic shock are all classified as distributive shock. Cardiogenic shock occurs when there is either systolic or diastolic dysfunction of the heart's pumping action, resulting in reduced cardiac output. Obstructive shock develops when a physical obstruction to blood flow occurs with a decrease in cardiac output. Hypovolemic shock occurs after a loss of intravascular fluid volume.

Which immediate effects of the inflammatory response precedes multiple organ dysfunction syndrome (MODS)? Select all that apply. Organ damage Hypermetabolism Microvascular clots Increased vascular permeability Direct damage of the endothelium Mediators leak out of the endothelium

Hypermetabolism Increased vascular permeability Direct damage of the endothelium Rationale Inflammatory cascade causes direct damage of the endothelium, increased vascular permeability, and hypermetabolism quickly. Vascular permeability allows mediators and proteins to leak from the endothelium further on in the cascade; microvascular clots are a late effect of inflammation that will eventually lead to impaired perfusion, and finally organ damage, which precipitates MODS.

Which electrolyte change is likely in patients with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS)? Hyperkalemia Hyponatremia Hypercalcemia Hypophosphatemia

Hypophosphatemia Rationale In patients with SIRS and MODS, hypophosphatemia is common. The release of aldosterone increases urinary potassium loss, and catecholamines cause potassium to move into the cells. As a result, hypokalemia rather than hyperkalemia occurs. The release of antidiuretic hormone and aldosterone results in sodium and water retention. Hence, hyponatremia does not occur. Other changes include hypocalcemia rather than hypercalcemia. pp. 1584-1585

Which cardiovascular change is commonly found in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Hypotension Vasoconstriction Increased venous return Decreased cardiac output

Hypotension Rationale Hypotension is commonly found in patients with SIRS and MODS. It results from vasodilation in response to the increase in tissue demands. Vasodilation, not vasoconstriction, causes a decrease in venous return. In addition, the increase in capillary permeability resulting in a shift of albumin and fluid out of the vascular space also causes a decrease in venous return. As a response to the decrease in venous return and BP, the baroreceptor reflex causes the release of inotropic and chronotropic factors. There is an increase in the force of contraction and heart rate resulting in an increase in cardiac output.

Which laboratory value would the nurse monitor to measure the byproduct of anaerobic metabolism in a patient with sepsis? Lactic acid Base deficit Blood cultures Arterial blood gas

Lactic acid Rationale Lactic acid is the measurement of the byproduct of anaerobic metabolism caused by significant hypoperfusion and impaired oxygen utilization at the cellular level in sepsis patients. Base deficit indicates acid production secondary to hypoxia. Blood cultures are used to determine the organism causing infection. Arterial blood gas measures respiratory alkalosis in early stages of septic shock and metabolic acidosis in late stages of septic shock.

Which prescriptions would the nurse anticipate incorporating into the plan of care for a patient with multiple organ dysfunction syndrome (MODS) who is exhibiting gastrointestinal symptoms including bleeding? Select all that apply. Maalox Sucralfate Atorvastatin Loperamide Omeprazole

Maalox Sucralfate Omeprazole Rationale Antacids like Maalox, proton pump inhibitors like omeprazole, and sucralfate are all indicated to treat issues related to injury to the gastric mucosa in MODS. Atorvastatin is a cholesterol-lowering agent and thus not indicated in this situation. Loperamide is an antidiarrheal and not appropriate based on the information provided.

Which therapy would the nurse incorporate into the plan of care for a patient with acute respiratory distress syndrome (ARDS)? Mechanical ventilation Oxygen via a Venturi mask Oxygen via a non-rebreather mask Small volume nebulizer treatments

Mechanical ventilation Rationale A patient with ARDS would be intubated and receive mechanical ventilation. Small volume nebulizer treatments would open airways; however, this intervention will not sufficiently treat ARDS. Oxygen via a Venturi mask or a non-rebreather mask would be insufficient to promote oxygenation and perfusion. p. 1584

Which medical emergency is caused by the failure of two or more organ systems? Crush syndrome Toxic shock syndrome Multiple organ dysfunction syndrome (MODS) Systemic inflammatory response syndrome (SIRS)

Multiple organ dysfunction syndrome (MODS) Rationale MODS is caused by the failure of two or more organ systems in an acutely ill patient. A crushing injury to the skeletal muscle causes crush syndrome, which is characterized by shock and renal failure. Bacterial toxins cause toxic shock syndrome, which is characterized by high fever, hypotension, and malaise. SIRS is a systemic inflammatory response caused by infection, ischemia, infarction, and injury.

Which type of shock can be treated by minimizing spinal cord trauma with stabilization? Septic shock Neurogenic shock Anaphylactic shock Hypovolemic shock

Neurogenic shock Rationale Neurogenic shock is caused by severe injury to the spinal cord and results in loss of sympathetic stimulation of blood vessels. Apart from administering vasoconstrictor agents, minimizing the spinal cord trauma with stabilization is a supporting therapy for neurogenic shock. Septic shock occurs in response to a systemic infection. Obtaining the cultures before starting antibiotics is appropriate care for septic shock. A life-threatening allergic reaction to a sensitizing substance causes anaphylactic shock. Avoiding exposure to allergens is supportive therapy for anaphylactic shock. Excessive loss of intravascular fluid causes hypovolemic shock. Besides restoring fluid volume, correcting the cause of fluid loss is supportive therapy.

Which interventions would the nurse expect to perform for a patient with multiple organ dysfunction syndrome who is at risk for bleeding? Select all that apply. Decrease fluid intake. Observe bleeding sites. Provide enteral feedings. Minimize traumatic interventions. Administer platelets and clotting factors.

Observe bleeding sites. Minimize traumatic interventions. Administer platelets and clotting factors. Rationale The patient with multiple organ dysfunction syndrome is at a risk for bleeding due to increased bleeding time, thrombocytopenia, and dysfunctional clotting process. The nursing interventions should be aimed at preventing potential bleeding and replacing factors being lost. The patient should be observed for frank or occult bleeding from potential sites. The factors like platelets and clotting factors should be replaced if deficient. Traumatic interventions, such as IM injections or multiple venipunctures, should be avoided. Decreasing the fluid intake and providing enteral feedings will not help to minimize hematologic complications. pp. 1584-1585

The nurse is caring for a patient with a tension pneumothorax. Which type of shock would the patient monitor for? Septic Obstructive Hypovolemic Anaphylactic

Obstructive Rationale The nurse recognizes these as signs of obstructive shock, which is a result of a physical obstruction of blood flow and can be related to tension pneumothorax, pulmonary embolism, and cardiac tamponade. Hypovolemic shock is a result of low blood volume. Septic shock is a result of a serious infection that has compromised cellular, circulatory, and metabolic function. Anaphylactic shock is a result of hypersensitivity to a sensitizing substance.

A patient with multiple organ dysfunction syndrome (MODS) has a temperature of 102.2 o F and copious amounts of purulent drainage and redness surrounding a diabetic wound. Which action would be the nurse's priority? Place the patient in isolation. Obtain wound and blood cultures. Initiate broad-spectrum antibiotic therapy. Change the dressing on the wound using strict sterile technique.

Obtain wound and blood cultures. Rationale The immediate need when an infection is suspected in a MODS patient is to determine the cause; thus, wound and blood cultures would be the first action. Placing a patient in isolation would not be the priority action. Depending on the cultures, the patient may need to be placed in contact isolation depending on the type of infection. Antibiotics would be started after the cultures are obtained and sent for analysis. The dressing may need to be changed, but this would not be the first action of the nurse.

Which nursing assessment finding is most concerning in a patient experiencing cardiogenic shock? PaO 2 60 mm Hg Heart rate 96 beats/minute BP 100/56 mm Hg Urine output 260 mL in 8 hours

PaO 2 60 mm Hg Rationale A PaO 2 of 60 is below the normal 80 to 100 mm Hg. The patient experiencing cardiogenic shock will exhibit hypotension and tachycardia, and therefore a BP of 100/56 mm Hg and heart rate of 96 would not apply. A urine output of 260 mL/8 hours is borderline but not reportable without a continued trending pattern. p. 1570

Which goal would the nurse use when caring for a patient with systemic inflammatory response syndrome (SIRS) whose bilirubin level is 3 mg/dL? Patient will be free of stress ulcers. Patient will not feel abdominal distension. Patient will maintain adequate tissue perfusion. Patient will maintain intraabdominal pressures.

Patient will maintain adequate tissue perfusion. Rationale The nurse will plan to maintain adequate tissue perfusion for a systemic inflammatory response syndrome (SIRS) patient with bilirubin level of 3 mg/dL. An elevation of the bilirubin indicates impaired liver function. Stress ulcer prophylaxis is routine and would have been initiated before SIRS occurred. Abdominal distention and increased intraabdominal pressures are associated with impaired liver function. Monitoring these conditions is essential but is of a lower priority than maintaining tissue perfusion. pp. 1584-1585

Which actions would the nurse take to safely administer sodium nitroprusside to a patient in cardiogenic shock? Select all that apply. Avoid using with D 5W. Protect solution from light. Monitor the body temperature. Wrap infusion bottle with opaque covering. Monitor the serum cyanide levels and signs of cyanide toxicity.

Protect solution from light. Wrap infusion bottle with opaque covering. Monitor the serum cyanide levels and signs of cyanide toxicity. Rationale Sodium nitroprusside is a vasodilator used in cardiogenic shock. The drug tends to release cyanide ions when exposed to sunlight. Therefore, it should be protected from exposure to sunlight by wrapping the infusion bottle with an opaque covering. The patient's serum cyanide levels should be checked, and the patient should be monitored for signs of cyanide toxicity. This includes metabolic acidosis, tachycardia, altered level of consciousness, seizures, coma, and almond smell on the breath. The medication should be reconstituted with D 5W only. Monitoring vital signs like body temperature is important but may not directly impact the treatment being administered.

Which nutritional component is most important for a patient with multiple organ dysfunction syndrome (MODS)? Protein Vitamins Minerals Carbohydrates

Protein Rationale Protein and calorie malnutrition is one of the primary signs of hypermetabolism in MODS. The goal of nutritional support is to preserve organ function by providing early and optimal nutrition. Vitamins, minerals, and carbohydrates may be incorporated into the patient's nutrition plan but are not as helpful as protein and calories. pp. 1577, 1584

Which laboratory results indicate involvement of the hematologic system in a patient diagnosed with multiple organ dysfunction syndrome (MODS) after a traumatic injury? Select all that apply. Hematocrit (Hct) 42% Prothrombin time (PT) 18 seconds Red blood cells (RBCs) 5.0 x 10 6/μL D-Dimer 280 ng/mL Platelets 125 x 10 3/μL

Prothrombin time (PT) 18 seconds D-Dimer 280 ng/mL Platelets 125 x 10 3/μL Rationale Increased PT, increased D-dimer, and decreased platelets indicate involvement of the hematologic system. Normal PT is 11 to 16 seconds; normal platelets are 150 to 400 x 10 3/ μL, and normal D-dimer is less than 250 ng/mL. These all indicate involvement of the hematologic system. Normal Hct is 39% to 50% for males and 35% to 47% for females; thus, this result is within normal range. RBC values range from 3.8/4.3 to 5.1/5.7 x 10 6/μL (male/female); thus, this result is within normal limits. p. 1585

Which laboratory results would indicate possible development of multiple organ dysfunction syndrome (MODS)? Select all that apply. Alanine transaminase (ALT) 8 U/L Increased systemic vascular resistance (SVR) Pulmonary artery wedge pressure (PAWP) 15 mm Hg Platelets 100,000 μL Urine-specific gravity 1.042

Pulmonary artery wedge pressure (PAWP) 15 mm Hg Platelets 100,000 μL Urine-specific gravity 1.042 RationaleA PAWP below 18 mm Hg, decreased platelet count (normal 150,000 to 400,000 μL), and increased urine- specific gravity (normal 1.003 to 1.030) are signs of failure in more than one organ system and potential development of MODS. An increased, not decreased, ALT (normal 10 to 40 U/L) and decreased, not increased, SVR (normal 800 to 1200 dynes/sec/cm -5) would be signs of MODS. pp. 1584-1585

Which system shows initial signs of dysfunction in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Respiratory system Cardiovascular system Gastrointestinal system Central nervous system

Respiratory system Rationale The pulmonary vasculature is directly affected by inflammatory mediators. Hence the initial signs of dysfunction in SIRS and MODS are seen in the respiratory system. Cardiovascular changes are detected later when there is myocardial depression. Effects on the gastrointestinal system are seen when the motility gets decreased. Central nervous system dysfunctions are seen when the patient's mental status begins to show signs of change. pp. 1584-1585

Which goal for fluid resuscitation would the nurse choose when caring for a patient diagnosed with sepsis? Restore tissue perfusion. Increase circulating fluid volume. Restore blood flow to the myocardium. Maintain a mean arterial pressure of 50 mm Hg.

Restore tissue perfusion. Rationale The goal for fluid resuscitation is the restoration of tissue perfusion. Increasing circulating fluid volume is the goal for hypovolemic shock. Restoring blood flow to the myocardium is the goal for cardiogenic shock. Maintaining a mean arterial pressure of 65 mm Hg is the goal when using vasopressors. p. 1576

Which conditions can cause hypovolemic shock? Select all that apply. Ruptured spleen Valvular stenosis Bowel obstruction Diabetes insipidus Tension pneumothorax

Ruptured spleen Bowel obstruction Diabetes insipidus Rationale Hypovolemic shock may be caused due to bowel obstruction, a ruptured spleen, or diabetes insipidus. Bowel obstruction causes relative hypovolemia by preventing fluid absorption for the bowel. A ruptured spleen may cause massive internal bleeding, leading to hypovolemia. Diabetes insipidus causes a marked increase in fluid loss through the kidneys, leading to hypovolemia. A tension pneumothorax and valvular stenosis may lead to cardiogenic shock.

The nurse provides care for a patient with sepsis and identifies that which assessment finding is associated with heart failure (HF)? Diaphoresis Piloerection S 3 heart sound A heart rate of 92 beats/min

S 3 heart sound Rationale An S 3 heart sound usually indicates the patient is experiencing heart failure. Diaphoresis and piloerection are associated with hypoperfusion. A heart rate of 92 beats/min is within normal range.

Vasopressor agents are prescribed for which types of shock? Select all that apply Septic Neurogenic Obstructive Cardiogenic Hypovolemic

Septic Neurogenic Rationale Septic shock occurs in response to an infection. It is associated with the release of cytokines and other inflammatory mediators, resulting in vasodilatation, increased capillary permeability, and platelet aggregation. Vasopressors will constrict the blood vessels and relieve hypotension. Neurogenic shock is caused by a severe injury to the central nervous system (CNS), causing a loss of sympathetic stimulation of blood vessels resulting in vasodilatation. A fall in BP can be restored by administering vasopressor agents that act by constricting the blood vessels. Obstructive shock is caused by an obstruction in the vessels of the heart or the heart itself. Restoring the circulation by treating the cause of obstruction will be beneficial for a patient with obstructive shock. Systolic or diastolic dysfunction of the heart results in cardiogenic shock. Treatment involves use of nitrates, inotropes, diuretics, and β-blockers. A loss in the intravascular fluid volume causes hypovolemic shock. Treatment of hypovolemic shock includes restoring the fluid volume by infusion of blood or blood products and crystalloids. Test-Taking Tip: Identify option components as correct or incorrect. This may help you to identify a wrong answer. p. 1579

Which types of shock may cause reduced urinary output in a patient? Select all that apply. Septic Obstructive Neurogenic Cardiogenic Hypovolemic Anaphylactic

Septic Obstructive Cardiogenic Hypovolemic Rationale Decreased urine output is a clinical manifestation of septic, hypovolemic, obstructive, and cardiogenic shock. Neurogenic shock is associated with bladder dysfunction. Anaphylactic shock is associated with urinary incontinence.

The nurse discusses treatment of septic shock with a group of nursing students. The nurse explains that a passive leg raise challenge is performed for which purpose? To increase the patient's BP To decrease the workload of the heart To assess the response to fluid replacement To improve the blood flow to the vital organs

To assess the response to fluid replacement Rationale A passive leg raise challenge allows the nurse to assess the patient's response to fluid replacement. The passive leg raise challenge is not intended to increase the patient's BP, decrease the workload of the heart, or improve blood flow to the vital organs. p. 1579

The nurse provides care for a patient with neurogenic shock whose spine has been stabilized. The nurse prioritizes treatment of the patient's hypotension and bradycardia for which primary purpose? To restore circulating volume To prevent oxygen loss to the brain To restore the oxygen delivery to the heart To prevent further spinal cord damage

To prevent further spinal cord damage Rationale The primary purpose of restoring the hypotension and bradycardia of a patient experiencing neurogenic shock is to prevent further spinal cord damage. Restoring circulatory volume is a goal for the patient with hypovolemic and septic shock. The primary treatment of hypotension and bradycardia for a patient with spinal cord damage is not to prevent oxygen loss to the brain. Restoring oxygen delivery to the heart is a goal for a patient with cardiogenic shock. p. 1579

Which finding in a patient with multiple organ dysfunction syndrome (MODS) suggests that the patient has acute tubular necrosis? Bilirubin is 3 mg/dL. Urine Na + is 22 mEq/L. Urine-specific gravity is 1.026.Blood urea nitrogen (BUN)/creatinine ratio is 22:1.

Urine Na + is 22 mEq/L. RationaleA urine Na + greater than 20 mEq/L is suggestive of acute tubular necrosis. A bilirubin level higher than 2 mEq/L suggests hepatic dysfunction rather than renal dysfunction. Urine-specific gravity above 1.020 and a BUN/creatinine ratio higher than 20:1 indicate renal hypoperfusion rather than acute tubular necrosis. pp. 1584-1585

Which laboratory finding in a patient with multiple organ dysfunction syndrome (MODS) suggests prerenal manifestations of renal dysfunction? Urine Na + is 22 mEq/L .Urine specific gravity is 1.010. Urine osmolality is decreased. Urine specific gravity is increased.

Urine specific gravity is increased. Rationale An increase in urine specific gravity suggests prerenal manifestations in patients with MODS. This occurs due to renal hypoperfusion. A urine Na + level above 20 mEq/L is a sign of intrarenal manifestations in MODS. It occurs due to acute tubular necrosis. Other intrarenal manifestations of MODS are urine specific gravity of around 1.010 and a decrease of the urine osmolality.

Which elements are included in the assessment of the tissue perfusion of a patient experiencing shock? Select all that apply. Vital signs Urine output Lung sounds Peripheral pulses Skin temperature Level of consciousness

Vital signs Urine output Peripheral pulses Skin temperature Level of consciousness Rationale Assessing tissue perfusion includes evaluating vital signs, level of consciousness, peripheral pulses, capillary refill, skin (e.g., temperature, color, moisture), and urine output. Assessment of the patient's lung sounds is not part of the assessment of tissue perfusion. p. 1581