Prep U Ch 14
A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to
Encourage the family to touch and talk to the client.
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?
Head injury
The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?
Increase the force of myocardial contraction
The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following?
The difference between the systolic and diastolic pressure
A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first?
Administer an epinephrine injection.
You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client?
Adrenergic drugs
Which type of shock occurs from an antigen-antibody response?
Anaphylactic
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?
Aortic insufficiency
During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?
Brain
A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices?
Hanging tape on the bedside table when changing a wet-to-dry sterile dressing
You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client?
Increases myocardial contractility
Which stage of shock would encompass mechanical ventilation, altered level of consciousness, and profound acidosis?
Irreversible
The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock?
It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.
A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction:
Jugular venous distention
A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption?
Morphine
The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
Multiple organ failure
A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:
Oxygen at 2 L/min by nasal cannula
The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation?
Pedal pulse stronger
The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?
Place the client in a modified Trendelenburg position.
The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.
Place the client in a modified Trendelenburg position.
A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as
Progressive
A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy:
The right foot is cooler than the left foot.
What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?
Use strict hand hygiene techniques.
The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?
WBC: 42,000/mm3
A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn mediciations would the nurse administer next?
ondansetron (Zofran)
The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.)
• Activation of the inflammatory response • Hypoperfusion of tissues • Must produce energy through anaerobic metabolism
Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply.
• Famotidine (Pepcid) • Ranitidine (Zantac) • Lansoprazole (Prevacid)
The nurse is caring for a patient with a central venous line in place for the treatment of shock. Which of the following nursing interventions are essential for the nurse to complete to reduce the risk of infection? Select all that apply.
• Maintain sterile technique when changing the central venous line dressing. • Always perform hand hygiene before manipulating or accessing the line ports. • Wear clean gloves prior to accessing the line port.
When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.)
• Urinary output • Mental status • Vital signs
Which positioning strategy should be used for the patient diagnosed with hypovolemic shock?
Modified Trendelenburg
A nurse knows that the major clinical use of dobutamine (Dobutrex) is to:
increase cardiac output.
For which of the following patients in shock would a nurse observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment?
A patient with an overwhelming bacterial infection
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:
A myocardial infarction.
It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.
A patient with an overwhelming bacterial infection
When vasoactive medications are administered, the nurse must monitor vital signs at least how often?
15 minutes
The nurse is caring for a patient in cardiogenic shock. A dobutamine (Dobutrex) drip at 1 μg/kg/min is ordered for the patient. The patient weighs 90 kg. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many mL/hr?
2.7 mL/hr
The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition?
300 mL
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?
5% albumin
Which of the following blood pressure (BP) readings would result in a pulse pressure indicative of shock?
90/70 mm Hg
A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse
Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix)
The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient?
Disseminated intravascular coagulation (DIC)
The nurse caring for a patient post epidural anesthesia notices that the patient is beginning to evidence symptoms of shock. The nurse assesses the patient for what type of shock?
Distributive
A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm?
Epinephrine
A patient presents to the emergency department after being stung by a bee, complaining of difficulty breathing. What vasoconstrictive medication should be given at this time?
Epinephrine Anaphylactic shock is caused by a severe allergic reaction, such as to a bee sting, when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen- antibody reaction; specifically, an immunoglobulin E (IgE)- mediated response (see Chart 14-4). Intramuscular epinephrine is administered for its vasoconstrictive action. Diphenhydramine (Benadryl) is administered IV to reverse the effects of histamine, thereby reducing capillary permeability. Dexamethasone and prednisone are corticosteroids, which treat inflammation; they do not have vasoconstrictive properties, however.
A patient presents to the emergency department (ED) with her husband. The patient appears in respiratory distress. The husband states "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which of the following agents first?
Epinephrine (Adrenalin) intramuscularly (IM)
The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following?
Low
A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess
Lung sounds
A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position?
Modified Trendelenburg
You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do?
Restores blood pressure
The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?
Septic
The nurse anticipates that a patient who is immunosuppressed is at the greatest risk for developing which of the following types of shock?
Septic
When a patient is in the compensatory stage of shock, which of the following symptoms occurs?
Tachycardia