Week 5
When performing a physical assessment of a patient with severe sepsis, what abnormal assessment would the nurse expect to find? a.) A WBC of 8,100 despite the presence of chills. b.) A blood pressure of 100/72 with a capillary refill of <3 seconds. c.) Leucocytosis in a patient with absent bowel sounds .d.) Renal output that fluctuates according to intravenous intake.
C
Which manifestations of shock are a result of compensatory mechanisms to maintain circulating blood volume? A) Edema and weight gain B) Confusion and lethargy C) Decreased urine output and thirst D) Increased pulse and respiratory rates
C
Which of the following assessment findings is an early indication of hypovolemic shock? a.) Diminished bowel sounds b.) Increased urinary output c.) Tachycardia d.) Hypertension
C
A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the clients bed. d. Tell the client everything possible is being done.
A
Which type of fluid is most appropriate for volume replacement for a patient with non-hemorrhagic hypovolemic shock? a.) Lactated Ringers (LR) b.) 10% Dextrose in Water (D 10 W) c.) One-half Normal Saline (1/2% NS) d.) Packed Red Blood Cells (PRBC)
A
What is the priority nursing responsibility in the prevention of shock? a. frequently monitoring all patient's vital signs b. using aseptic technique for all invasive procedures c. being aware of the potential for shock in all patients at risk d. teaching the patients health promotion activities to prevent shock
C
When administering any vasoactive drug during treatment of shock, the nurse should know that what is the goal of the therapy? a. increasing urine output to 50 mL/hr b. constriction of vessels to maintain BP c. maintaining a MAP of at least 65 mm/Hg d. dilating vessels to improve tissue perfusion
C
When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a.) BP 88/56 mm Hg b.) Apical pulse 110 beats/min c.) Urine output 15 ml for 2 hours d.) Arterial oxygen saturation 90%
C
After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris) .c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
c
A patient is being treated for pericarditis. The nurse will plan interventions to prevent the onset of which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic
1
A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? 1. Jugular vein distention 2. Dry mucous membranes 3. Poor skin turgor 4. Thirst
1
A patient is demonstrating signs of obstructive shock but the cause has yet to be determined. Which finding indicates the patient is experiencing a pulmonary embolism as the cause for obstructive shock? 1. Chest pain 2. Hypotension 3. Tachycardia 4. Oliguria
1
A patient is diagnosed with cardiac tamponade. When planning care, the nurse will include interventions to address which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic
1
A patient is experiencing an anaphylactic reaction to a medication. The nurse is concerned that the patient will develop distributive shock because: 1. The release of histamine causes vasodilation with plasma leakage. 2. Sympathetic innervation is interrupted. 3. Microorganisms overwhelm the vascular system. 4. Parasympathetic innervation functions are unopposed.
1
A patient is prescribed vasopressin 0.03 units/minute as treatment for septic shock. What action will the nurse take when providing this medication? 1. Provide the vasopressin infusion in addition to a norepinephrine infusion. 2. Infuse through a peripheral line. 3. Utilize a rapid infuser. 4. Administer with 0.9% normal saline.
1
A patient is receiving phenylephrine 50 mcg/min as treatment for shock. Which assessment finding indicates this medication is effective? 1. Blood pressure 110/68 mm Hg 2. Heart rate 110 3. Respiratory rate 12 and regular 4. Decreased peripheral pulses
1
A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: 1. Reduced cardiac output 2. Increased stroke volume 3. Reduced blood volume 4. Blood flow blocked in the pulmonary circulation
1
The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive
1
Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? 1. Reduced wheezing 2. Heart rate 55 and regular 3. Blood pressure 98/50 mm Hg 4. Respiratory rate 28
1
Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 8 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54%
1
The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Age 80 2. History of atrial fibrillation 3. Bacteremia 4. T3 spinal cord injury5. Latex allergy
1,2
A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Elevated pulmonary arterial wedge pressure 2. Elevated central venous pressure 3. Elevated systemic vascular resistance index 4. Elevated mean arterial pressure 5. Elevated stroke volume
1,2,3
A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Administer epinephrine 1:1000 intramuscularly. 2. Apply oxygen via face mask as prescribed. 3. Provide diphenhydramine 25 mg intravenous. 4. Administer vasopressin. 5. Prepare to administer antithrombolytic agents as prescribed.
1,2,3
A patient is receiving norepinephrine 30 mcg/min for treatment of refractory shock. Which assessment findings suggest the patient is experiencing peripheral vasoconstriction from the medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Decreased peripheral pulses 2. Drop in body temperature 3. Onset of paresthesias 4. Drop in blood pressure 5. Increased cardiac output
1,2,3
A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Sepsis 2. Spinal cord injury 3. Anaphylaxis 4. Hemorrhage 5. Pulmonary embolism
1,2,3
During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply .1. Systolic blood pressure 82 mm Hg 2. Capillary refill 10 seconds 3. Crackles bilateral lung bases 4. Heart rate 55 and regular 5. Warm dry skin
1,2,3
The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations
1,2,3
A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Recent bee sting 2. Ingestion of drugs 3. History of latex allergy 4. Recent diagnostic imaging tests 5. Recent myocardial infarction
1,2,3,4
The nurse is explaining the mechanism of a pulmonary embolism to the family of a patient diagnosed with the disorder. Place in order the steps the nurse will use to instruct the family about this disease process. Standard Text: Click and drag the options below to move them up or down. Choice 1. Blood clot causes backup of blood in the right ventricle. Choice 2. Blood clot blocks blood to the left ventricle. Choice 3. Left ventricle does not get enough blood to pump through the body. Choice 4. Amount of blood the heart has to pump to the body drops. Choice 5. Blood pressure drops. Choice 6. Amount of blood going to the body drops.
1,2,3,4,5,6
The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Dopamine 2. Norepinephrine 3. Dobutamine 4. Epinephrine 5. Phenylephrine
1,2,3,5
A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? A. Report chest heaviness B. Pedal pulses 1+/4+ bilaterally C. Blood pressure 98/68 mmHg D. Urine output of 32 mL/hr
A
A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Anaphylactic 4. Obstructive
2
The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication? 1. Hemorrhagic shock 2. Hypothermia 3. Sepsis 4. Cardiogenic shock
2
Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time
2
Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%
2
Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringer's lactate (RL) over 15 minutes 3. Two liters of D5W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour
2
Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema
2, 3
What will the nurse identify as symptoms of hypovolemic shock in a patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Temperature of 97.6°F (36.4°C) 2. Restlessness 3. Decrease in blood pressure of 20 mm Hg when the patient sits up 4. Capillary refill time greater than 3 seconds 5. Sinus bradycardia of 55 beats per minute
2, 3, 4
The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions: 1. Move quickly into the interstitial spaces and can cause third spacing 2. Stay longer to expand the intravascular space but deplete intracellular fluid levels 3. Do not stay in the intravascular space long enough to expand the circulating blood volume 4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low
3
The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output 2. Severe constipation, causing watery diarrhea 3. Ascites 4. Syndrome of inappropriate ADH (SIADH)
3
A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time? 1. Limit patient movement 2. Prepare to administer crystalloids. 3. Administer phenylephrine as prescribed .4. Administer atropine as prescribed.
4
A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin when the client is not a diabetic. What response by the nurse is best? A. High glucose is common in shock and needs to be treated B. The stress of this illness has made your spouse diabetic C. The IV solution has lot's of glucose which raises blood sugar. D. Some of the medications we are giving are to raise blood sugar.
A
A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours
A
A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? A. Temperature B. Pulse C. Respiration D. Blood pressure
A
A nurse is caring for a client who has a prescription for an afterload-reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? a. cardiogenic b. obstructive c. hypovolemic d. distributive
A
A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a.) The cardiac output is elevated. b.) The central venous pressure (CVP) is increased. c.) The systemic vascular resistance (SVR) is high .d.) The PAWP is high.
A
A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock? a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Distributive
A
A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a.) urine output of 0.5 ml/kg/hr. b.) decreased peripheral edema. c.) decreased CVP. d.) oxygen saturation 90% or more.
A
A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate: a.) administration of furosemide (Lasix) IV. b.) titration of an epinephrine (Adrenalin) drip. c.) administration of a normal saline bolus. d.) assisting with endotracheal intubation.
A
A patient with hypovolemic shock is receiving lactated Ringer's solution for fluid replacement therapy. During this therapy, which laboratory result is most important for the nurse to monitor? a. serum pH b. serum sodiumc c. serum potassium d. hemoglobin and hematocrit
A
Nursing assessment of a client receiving serum albumin for treatment of shock should include: a.) Assessing lung sounds. b.) Monitoring glucose. c.) Monitoring the potassium level. d.) Monitoring hemoglobin and hematocrit.
A
The client in shock is prescribed an infusion of lactated Ringer's solution. The nurse recognizes that the function of this fluid in the treatment of shock is to: a.) Replace fluid, and promote urine output. b.) Draw water into cells. c.) Draw water from cells to blood vessels. d.) Maintain vascular volume.
A
The client with which problem is at highest risk for hypovolemic shock? A. Esophageal varices B. Kidney failure C. Arthritis and daily acetaminophen use D. Kidney stone
A
The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a.) urine output is 40 ml over the last hour. b.) hemoglobin is within normal limits. c.) CVP has decreased. d.) mean arterial pressure (MAP) is 65 mm Hg.
A
The nursing assistant reports concerns about the postoperative client who has BP 90/60, HR 80, R 22. What should the RN do? A. Compare these VS with last several readings B. Request that the surgeon come see the client C. Increase the rate of IV fluids D. Reassess VS using different equipment
A
When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the a.) cardiac output is increased and the central venous pressure (CVP) is low. b.) pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low. c.) heart rate is decreased, and the systemic vascular resistance is low. d.) cardiac output is decreased and the PAWP is high.
A
When caring for a patient in acute septic shock, what should the nurse anticipate? a Infusing large amounts of IV fluids b Administering osmotic and/or loop diuretics c Administering IV diphenhydramine (Benadryl) d Assisting with insertion of a ventricular assist device (VAD)
A
When caring for a patient in acute septic shock, what should the nurse anticipate? a. Infusing large amounts of IV fluids b. Administering osmotic and/or loop diuretics c. Administering IV diphenhydramine (Benadryl) d. Assisting with insertion of a ventricular assist device (VAD)
A
Which change in the client with hypovolemic shock indicates to the nurse that treatment is effective? A. Urine output increases from 5mL/hr to 25mL/hr B. Pulse pressure decreases from 35mmHg to 28mmHg C. Respiratory rate increases from 22/minute to 26/minute D. Body temperature increases from 98.2F to 98.8F
A
Which interventions may prevent GI bacterial endotoxin translocation in a critically ill patient with SIRS? a. early enteral feedings b. surgical removal of necrotic tissue c. aggressive multiple antibiotic therapy d. strict aseptic technique in all procedures
A
The patient is in the compensatory stage of shock. What manifestations indicate this to the nurse? (Select all that apply) a. pale and cool b. unresponsive c. lower BP than baseline d. moist crackles in the lungs e. hyperactive bowel sounds f. tachypnea and tachycardia
A, C, F
Which indicators of tissue perfusion should be monitored in critically ill patients by the nurse? (Select all that apply) a. skin b. urine output c. level of consciousness d. activities of daily living e. vital signs, including pulse oximetry f. peripheral pulses with capillary refill
A, B, C, E, F
The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutritione. Overhydration
A, B, C, D
A client who is in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which ones does the nurse attribute to ongoing compensatory mechanisms? Select all that apply. A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output
A, B, D, E, H
What physical problems could precipitate hypovolemic shock? (Select all that apply) a. burns b. ascites c. vaccines d. insect bites e. hemorrhage f. ruptured spleen
A, B, E, F
Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply): a. dobutamine to increase myocardial contractility b. vasopressors to increase systemic vascular resistance. c. circulatory devices such as an IABP d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. trendelenburg positioning to facilitate venous return and increase preload
A, C
The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusione. Increased perfusion
A, C
The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possiblee. Using aseptic technique during procedures
A, C, D, E
A 70-year-old patient in the ICU has become agitated and inattentive since his heart surgery. The nurse knows that this ICU psychosis frequently occurs in individuals with pre-existing dementia, history of alcohol abuse, and severe disease. What interventions should the nurse provide this patient to improve the patient's cognition (select all that apply)? a Improve oxygenation. b Provide a small amount of beer. c Have the family stay with the patient. d Enable the patient to sleep on a schedule with dim lights. e Decrease sensory overload by conversing away from patient's room.
A, D, E
A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the clients painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance
A, D, E
Which clients are at immediate risk for hypovolemic shock? (Select all that apply.) A. Unrestrained client in motor vehicle accident B. Construction worker C. Athlete D. Surgical intensive care clientE. 85-year-old with gastrointestinal virus
A, D, E
A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client:Select all that apply: a.) Rapid shallow respirations. b.) Severe hypotension. c.) Mental status changes. d.) Elevated temperature. e.) Lactic acidosis. f.) Oliguria.
A,D
The patient is admitted with an unusual infection. The nurse knows that a mechanical tissue trauma that can trigger SIRS will not occur with this patient because what types of injuries cause a mechanical tissue trauma trigger of SIRS? (Select all that apply) a. burns b. fungi c. viruses d. crush injuries e. surgical procedures
A,D,E
The following therapies are prescribed by the health care provider for a patient who has respiratory distress and syncope after a bee sting. Which will the nurse administer first? a. normal saline infusion b. epinephrine (Adrenalin) c. dexamethasone (Decadron) d. diphenhydramine (Benadryl)
b
The nurse would recognize which clinical manifestation as suggestive of sepsis? a. Sudden diuresis unrelated to drug therapy b. Hyperglycemia in the absence of diabetes c. Respiratory rate of seven breaths per minute d. Bradycardia with sudden increase in blood pressure
b
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2 F (38.4 C)
c
A patient's localized infection has become systemic and septic shock is suspected. What medication is expected to treat septic shock refractory to fluids? a. Insulin infusion b. Furosemide (Lasix) IV push c. Norepinephrine administered by titration d. Administration of nitrates and β-adrenergic blockers
c
A 50-year-old woman with a suspected brain tumor is scheduled for a computed tomography (CT) scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? A. Infuse IV diphenhydramine prior to the procedure. B. Administer lorazepam (Ativan) before the procedure. C. Complete the CT scan without the use of contrast media. D. Premedicate with hydrocortisone sodium succinate (Solu-Cortef).
B
A 50-year-old woman with a suspected brain tumor is scheduled for a computed tomography (CT) scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? a Infuse IV diphenhydramine prior to the procedure. b Administer lorazepam (Ativan) before the procedure. c Complete the CT scan without the use of contrast media. d Premedicate with hydrocortisone sodium succinate (Solu-Cortef).
B
A 50-yr-old woman with a suspected brain tumor is scheduled for a CT scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? a. Infuse IV diphenhydramine before the procedure. b. Administer lorazepam (Ativan) before the procedure. c. Complete the CT scan without the use of contrast media. d. Premedicate with hydrocortisone sodium succinate (Solu-Cortef).
B
A 64-year-old male patient admitted to the critical care unit for gastrointestinal hemorrhage complains of feeling tense and nervous. He appears restless with an increase in blood pressure and pulse. If the physical assessment shows no other changes, it is most important for the critical care nurse to take which action? a Administer prescribed IV dose of lorazepam (Ativan). b Stay with the patient and encourage expression of concerns. c Ask a family member to remain at the bedside with the patient. d Teach the patient how to use guided imagery to reduce anxiety.
B
A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? A. Obtain a 12-lead ECG and arterial blood gases. B. Rapidly administer 1000 mL normal saline solution IV. C. Administer norepinephrine (Levophed) by continuous IV infusion. D. Carefully insert a nasogastric tube and an indwelling bladder catheter.
B
A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? a Obtain a 12-lead ECG and arterial blood gases. b Rapidly administer 1000 mL normal saline solution IV. c Administer norepinephrine (Levophed) by continuous IV infusion. d Carefully insert a nasogastric tube and an indwelling bladder catheter.
B
A 64-yr-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure of 78/58 mm Hg, pulse of 124 beats/min, respirations of 28 breaths/min, and temperature of 97.2°F (36.2°C). Which physician order should the nurse complete first? a. Obtain a 12-lead ECG and arterial blood gases. b. Rapidly administer 1000 mL normal saline solution IV. c. Administer norepinephrine (Levophed) by continuous IV infusion. d. Carefully insert a nasogastric tube and an indwelling bladder catheter.
B
A 78 y.o. man has confusion and a temp of 104 F. He is a diabetic with purulent drainage from his right heel. After an infusion of 3L of normal saline solution, his assessment findings are BP 84/40, HR 110, RR 42/shallow, CO 8L/min and PAWP 4. This patient's symptoms are most likely indicative ofL a. sepsis b. septic shock c. MODS d. SIRS
B
A 78 year old man has confusion and temperature of 104. He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40, HR 110, RR 42 and shallow, CO 8L/min, and PAWP 4 mm Hg. This patient's symptoms are most likely indicative o a. sepsis b. septic shock c. multiple organ dysfunction syndrome d. systemic inflammatory response syndrome
B
A client brought to the emergency department after a motorcycle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the initial stage of hypovolemic shock? A. When was the last time you urinated B. What is your usual heart rate? C. Are you more thirsty that normal? D. Is your skin usually cool and pale?
B
A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3
B
A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? a. maintain adequate fluid volume with IV infusions b. administer antibiotic therapy c. monitor hemodynamic status d. administer vasopressor medication
B
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a.) check the blood pressure. b.) obtain an oxygen saturation. c.) attach a cardiac monitor. d.) check level of consciousness.
B
A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a.) Insert two 14-gauge IV catheters. b.) Administer oxygen at 100% per non-rebreather mask. c.) Place the patient on continuous cardiac monitor. d.) Draw blood to type and crossmatch for transfusions.
B
To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are a.) stool guaiac and bowel sounds. b.) lung sounds and oxygenation status. c.) serum creatinine and urinary output. d.) serum bilirubin levels and skin color.
B
A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a.) Administer all medications through the patient's indwelling central line. b.) Place the patient in a private room .c.) Restrict the patient to foods that have been well-cooked or processed. d.) Insert a nasogastric (NG) tube for enteral feeding.
B
A patient with a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the patient for early organ damage associated with MODS, what is most important for the nurse to assess? a. urine output b. breath sounds c. peripheral circulation d. central venous pressure
B
A patient with severe trauma has been treated for hypovolemic shock. The nurse recognizes that the patient is in the refractory stage of shock when what is found during an assessment? a. a respiratory alkalosis with a pH of 7.46 b. marked hypotension and refractory hypoxemia c. unresponsiveness that responds only to painful stimuli d. profound vasoconstriction with absent peripheral pulses
B
A postoperative client is admitted to the ICU with hypovolemic shock. Which nursing action should the nurse delegate to the experienced nursing assistant? A. Obtain vital signs every 15 minutes B. Measure hourly urine output C. Check oxygen saturation D. Assess level of alertness
B
An intensive care nurse, is assessing a patient with suspected sepsis. Which predisposing factors would expect to be found in the patient with septic shock? a.) A 45 year old client with a history of renal insufficiency. b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection. c.) A 27 year old with pyelonephritis responding to treatment with an antibiotic. d.) A 50 year old with community acquired tuberculosis.
B
Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: a.) Monitoring for fluid overload. b.) Monitoring for cardiac dysrhythmias. c.) Monitoring respiratory status. d.) Monitoring for hypotension.
B
How does the nurse recognize that the client with septic shock has severe tissue hypoxia? A. PaCO2 58mm Hg B. Lactate level 9.0mmol/L C. INR 1.6 D. Potassium 2.8mEq/mL
B
The client experiences shock following a spinal cord injury. This type of shock is classified as: a.) Hypovolemic. b.) Neurogenic. c.) Cardiogenic. d.) Anaphylactic.
B
The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include: a.) pH 7.48, PaCO2 33 mm Hg. b.) pH 7.33, PaCO2 30 mm Hg. c.) pH 7.41, PaCO2 50 mm Hg. d.) pH 7.38, PaCO2 45 mm Hg.
B
The nurse determines that a large amount of crystalloid fluids administered to a patient in septic shock is effective when hemodynamic monitoring reveals what? a. CO of 2.6 L/min b. CVP of 15 mm Hg c. PAWP of 4 mm Hg d. Heart rate of 106 bpm
B
The nurse is providing discharge teaching to the post-operative client. Which statement by the client indicates need for more teaching? A. "I must call the doctor if I develop a fever." B. "I will call my provider if I have any pain." C. "If the dressing gets soaked with bright red blood I will call the doctor." D. "If the incision is red and swollen, I will call the provider."
B
The nurse plans to administer an antibiotic to the client newly admitted with septic shock. Which of the following is the most appropriate action for the nurse to take first? A. Administer the antibiotic immediately B. Ensure that blood cultures were drawn C. Obtain signature for informed consent D. Take the client's vital signs
B
The nurse suspects sepsis as a cause of shock when the laboratory test results indicate a. hypokalemia b. thrombocytopenia c. decreased hemoglobin d. increased blood urea nitrogen (BUN)
B
The nurse would recognize which clinical manifestation as suggestive of sepsis? a Sudden diuresis unrelated to drug therapy b Hyperglycemia in the absence of diabetes c Respiratory rate of seven breaths per minute d Bradycardia with sudden increase in blood pressure
B
What abnormal finding should the nurse expect to find in early compensatory shock? a. metabolic acidosis b. increased serum sodium c. decreased blood glucose d. increased serum potassium
B
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a Increased serum albumin b Decreased respiratory compliance c Increased gastrointestinal (GI) motility d Decreased blood urea nitrogen (BUN)/creatinine ratio
B
When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be? a. distributive shock b. obstructive shock c. cardiogenic shock d. hypovolemic shock
B
Which hemodynamic monitoring description of the identified shock is accurate? a. tachycardia with hypertension is characteristic of neurogenic syndrome b. increased pulmonary artery wedge pressure (PAWP) and a decreased cardiac output occur in cardiogenic shock c. anaphylactic shock is characterized by increased systemic vascular resistance, decreased CO, and decreased PAWP d. in septic shock, bacterial endotoxins
B
Which laboratory result is seen in late sepsis? A. Decreased serum lactate B. Decreased segmented neutrophil count C. Increased numbers of monocytes D. Increased platelet count
B
Which patient manifestations confirm the development of MODS? a. upper GI bleeding, glasgow coma scale score of 7, and Hct of 25% b. elevated serum bilirubin, serum creatinine of 3.8, and platelet count of 15,000 c. urine output of 30 mL/hr, BUN of 45, and WBC of 1120 d. respiratory rate of 45, PaCO2 of 60 mm Hg, and chest x-ray with bilateral diffuse patchy infiltrates
B
Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? A. Client receiving a blood transfusion B. Client with severe ascites C. Client with myocardial infarction D. Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion
B
While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a.) cold, mottled extremities .b.) restlessness and apprehension. c.) a heart rate of 120 and cool, clammy skin. d.) systolic BP less than 90 mm Hg.
B
Appropriate treatment modalities for the management of cardiogenic shock include (Select all that apply) a. dobutamine to increase myocardial contractility b. vasopressors to increase systemic vascular resistance c. circulatory assist devices such as an intraaortic balloon pump d. corticosteroids to stabilize the cell wall in the infarcted myocardium e. trendelenburg positioning to facilitate venous return and increase preload
B, C
The hemodynamic changes the nurse expects to find after successful initiation of IABP therapy in a patient with cardiogenic shock include (select all that apply): a. decreased SV b. decreased SVR c. decreased PAWP d. increased diastolic BP e. a decreased myocardial oxygen consumption
B, C, D, E
A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? (Select all that apply) a. heart rate 60 bpm b. seizure activity c. respiratory rate 42 breaths/min d. increased urine output e. weak, thready pulse
B, C, E
Which of the following would indicate a positive outcome after starting dopamine (Intropin)? A. Hourly urine output of 10-18 mL B. BP 90/60 and MAP 70 C. Blood glucose 245 D. Serum creatinine 3.6mg/dL
B. BP 90/60 and MAP 70
A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr
C
A nurse is caring for a client who is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? a. methylprednisone b. diphenhydramine c. epinephrine d. dobutamine
C
A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a.) nitroglycerine (Tridil). b.) dobutamine (Dobutrex). c.) norepinephrine (Levophed) .d.) sodium nitroprusside (Nipride).
C
A patient in the progressive stage of shock has rapid, deep respirations. The nurse determines that the patient's hyperventilation is compensating for metabolic acidosis when the patient's arterial blood gas results include which of the following? a. pH 7.42, PaO2 80 mm Hg b. pH 7.48, PaO2 69 mm Hg c. pH 7.38, PaO2 30 mm Hg d. pH 7.32, PaO2 48 mm Hg
C
A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? a.) Distributive b.) Neurogenic c.) Obstructive d.) Cardiogenic
C
A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a.) activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b.) stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d.) movement of interstitial fluid to the intravascular space, increasing renal blood flow
C
A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a.) cool, clammy skin. b.) shortness of breath. c.) heart rate of 48 beats/min d.) BP of 82/40 mm Hg.
C
A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? A. Insulin infusion B. IV administration of epinephrine C. Aggressive IV crystalloid fluid resuscitation D. Administration of nitrates and β-adrenergic blockers
C
A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? a Insulin infusion b IV administration of epinephrine c Aggressive IV crystalloid fluid resuscitation d Administration of nitrates and β-adrenergic blockers
C
How does the nurse recognize that the client is in early stages of septic shock? A. Pallor and cool skin B. Blood pressure 84/50 C. Tachypnea & tachycardia D. Respiratory acidosis
C
Multiple organ dysfunction syndrome (MODS) develops in severe sepsis as a result of systemic inflammatory response syndrome (SIRS), disseminated intravascular coagulation and damage to the endothelium. Which of the following statements best describes the management of MODS? a.) The use of proton pump inhibitors and H2 agents to increase the pH of the stomach inhibit the development of stress ulcers, an ileus and malabsorption issues. b.) Maintaining ventilator settings that ensure a tidal volume of at least 6 mL/kg of body weight will keep the lungs from being injured by endothelial damage. c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s). d.) Much of the organ damage that occurs with MODS in the setting of severe sepsis is associated with pre-existing conditions.
C
To establish hemodynamic monitoring for a patient, the nurse zeroes the: a. cardiac output monitoring system to the level of the left ventricle b. pressure monitoring system to the level of the catheter tip located in the patient c. pressure monitoring system to the level of the atrium, identified as the phlebostatic axis d. pressure monitoring system to the level of the atrium, identified as the midclavicular line
C
Sepsis is the most common cause of disseminated intravascular coagulation (DIC). All of the following statements concerning this life threatening complications are true except: a.) The rapidity of onset is determined by the intensity of the trigger and is related to the condition of the patient's liver, bone marrow and endothelium. b.) In the early phase, the patient may demonstrate manifestations of thrombosis and microemboli. c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock. d.) The most critical intervention for DIC is the early identification and treatment of the underlying disorder.
C
The critical care nurse is caring for a 55-year-old man who has a catheter in the right radial artery that is being used for continuous arterial blood pressure monitoring following his abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention? a Calculated mean arterial pressure is 74 mm Hg. b Patient's head of bed elevation is at 30 degrees. c Capillary refill time in the right hand is 5 seconds. d Pressure bag attached to the arterial line is inflated to 270 mm Hg.
C
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a.) Antibiotics to treat the underlying infection. b.) Corticosteroids to reduce inflammation. c.) IV fluids to increase intravascular volume. d.) Vasopressors to increase blood pressure.
C
The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? A. Antibiotics are not useful once an infection has progressed to sepsis. B. Weaning the patient away from the ventilator is the top priority in sepsis. C. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. D. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.
C
The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? a Antibiotics are not useful once an infection has progressed to sepsis. bWeaning the patient away from the ventilator is the top priority in sepsis. c Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d The patient has recovered from sepsis if he has warm skin and ruddy cheeks.
C
The nurse is caring for a 29-yr-old man who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The attending physician states the patient has developed sepsis, and the family members have many questions. Which information should the nurse include when explaining the early stage of sepsis? a. Antibiotics are not useful when an infection has progressed to sepsis .b. Weaning the patient away from the ventilator is the top priority in sepsis. c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.
C
The nurse is caring for a 34-year-old woman with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment best indicates that the patient's condition is improving? a Cardiac output (CO) is 3.5 L/minute. b Central venous pressure (CVP) is 10 mm Hg. c Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. d Systemic vascular resistance (SVR) is 1500 dynes/sec/cm-5.
C
The nurse is caring for a 72-yr-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be mostconcerning? a. Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds b. Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding d. Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL
C
The nurse is caring for a group of clients at risk for sepsis. Which of the following puts the client at highest risk? A. Pernicious anemia B. Pericarditis C. Post-kidney transplant D. Client owns an iguana
C
The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory-assist device should the nurse expect to use for this patient? a Cardiopulmonary bypass b Impedance cardiography (ICG) c Intraaortic balloon pump (IABP) d Central venous pressure (CVP) measurement
C
With which client should the nurse remain alert for the possibility of sepsis and septic shock? A. 41-year-old man who sustained closed depression fractures of the face when hit with a baseball B. 53-year-old woman who had an open abdominal hysterectomy 3 days ago to remove several large fibroid tumors .C. 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago. D. 72-year-old man with severe allergies who is undergoing radiation therapy for early-stage prostate cancer.
C
The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are: a. BP, P, RR b. breath sounds, BP, body temp. c. Pulse pressure, LOC, and pupillary response d. LOC, urine output, and skin color/temp
D
A client is progressing into the third stage of shock. The nurse will expect this client to demonstrate:Choose all that apply :a.) Intractable circulatory failure. b.) Neuroendocrine responses. c.) Demonstrating MODS. d.) Buildup of metabolic wastes. e.) Profound hypotension .f.) Increase in lactic acidosis.
C, D
Which interventions should be used for anaphylactic shock? (Select all that apply) a. antibiotics b. vasodilators c. antihistamines d. oxygen supplementation e. colloid volume expansion f. crystalloid volume expansion
C, D, E, F
The nurse gets the hand-off report on four clients. Which client should the nurse assess first? A. Client with urine output of 40 mL/hr for the last two hours B. Client with a pulse change of 100 to 88 beats per minute C. Client with oxygen saturation unchanged at 94% D. Client with a blood pressure change of 128/74 to 110/88 mm Hg
D
Which statement describing systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is accurate? a. MODS may occur independently from SIRS b. all patients with septic shock develop MODS c. the GI system is often the first to show evidence of dysfunction in SIRS and MODs d. a common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin
D
A 68-year-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which action is most important for the nurse to take? a Use the open-suctioning technique. b Administer morphine for discomfort. c Limit noise and cluster care activities. d Elevate the head of the bed 30 degrees.
D
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? A. Acute pain B. Impaired tissue integrity C. Decreased cardiac output D. Ineffective tissue perfusion
D
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a Acute pain b Impaired tissue integrity c Decreased cardiac output d Ineffective tissue perfusion
D
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a. Acute pain b. Impaired skin integrity c. Decreased cardiac output d. Ineffective tissue perfusion
D
A nurse is caring for a client after surgery who is restless and apprehensive. The UAP reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? A. Assess the client for pain or discomfort B. Stay with the client and reassure him or her C. Reposition the client to the unaffected side D. Measure urine output from catheter
D
A nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock? a. a client who is having occasional PVCs on the ECG monitor b. a client who has been experiencing vomiting and diarrhea for several days c. a client who has a gram-negative bacterial infection d. a client who has a pulmonary arterial stenosis
D
A nurse is caring for several clients at risk for shock. Which lab value requires the nurse to communicate with the healthcare provider? A. sodium 150 mEq/L B. Creatinine 0.9 mg/dL C. White blood cell count: 11,000/mm3 D. Lactate: 6 mmol/L
D
A patient has a spinal cord injury at T4. Vital signs include falling BP with bradycardia. The nurse recognizes that the patient is experiencing? a. a relative hypovolemia b. an absolute hypovolemia c. neurogenic shock from low blood flow d. neurogenic shock from massive vasodilation
D
A patient has a spinal cord injury at T4. Vital signs include falling blood pressure and bradycardia. The nurse recognizes that the patient is experiencing a. a relative hypervolemia b. an absolute hypovolemia c. neurogenic shock from low blood flow d. neurogenic shock from massive vasodilation
D
A patient in shock has a nursing diagnosis of fear related to severity of condition and perceived threat of death as manifested by verbalization of anxiety about condition and fear of death. What is an appropriate nursing intervention for this patient? a. administer antianxiety agents b. allow caregivers to visit as much as possible c. call a member of the clergy to visit the patient d. inform the patient of the current plan of care and its rationale
D
A patient with acute pancreatitis is experiencing hypovolemic shock. Which initial orders for the patient will the nurse implement first? a. start 100 mL of normal saline at 500 mL/hr b. obtain blood cultures before starting IV antibiotics c. draw blood for hematology and coagulation factors d. administer high-flow oxygen (100%) with a non-rebreather mask
D
As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic change occurs related to the increased angiotensin II? a. vasodilation b. decreased BP and CO c. aldosterone release results in sodium and water excretion d. antidiuretic hormone release increases water reabsorption
D
Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? a Cardiac index (CI) 5 L/min/m2 b Central venous pressure 8 mm Hg c Mean arterial pressure (MAP) 86 mm Hg d Pulmonary artery pressure (PAP) 28/14 mm Hg
D
In late refractory shock in a patient with massive thermal burns, what should the nurse expect the patient's laboratory results to reveal? a. respiratory alkalosis b. decreased potassium c. increased blood glucose d. increased ammonia levels
D
Progressive tissue hypoxia leading to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contribute to this increasing tissue hypoxia? a. coronary artery constriction causes decreased perfusion b. cardiac vasoconstriction decreased blood flow to pulmonary capillaries c. increased capillary permeability and profound vasoconstriction cause increased hydrostatic pressure d. decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to the cells
D
The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations b. breath sounds, blood pressure, and body temperature c. pulse pressure, level of consciousness, and pupillary response d. level of consciousness, urine output, and skin color and temperature
D
The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a 22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident b 48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c 65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina d 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection
D
The nurse is assisting in the care of several patients in the critical care unit. Which patient is most at risk for developing multiple organ dysfunction syndrome (MODS)? a. A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture b. A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c. A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina d. A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection
D
The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a.) The patient is restless and anxious. b.) The patient has a heart rate of 134. c.) The patient has hypotonic bowel sounds. d.) The patient has a temperature of 94.1° F.
D
What is the key factor in describing any type of shock? a. hypoxemia b. hypotension c. vascular collapse d. inadequate tissue perfusion
D
What laboratory finding fits with a medical diagnosis of cardiogenic shock? A. Decreased liver enzymes B. Increased white blood cells C. Decreased red blood cells, hemoglobin, and hematocrit D. Increased blood urea nitrogen (BUN) and serum creatinine levels
D
What laboratory finding fits with a medical diagnosis of cardiogenic shock? a Decreased liver enzymes b Increased white blood cells c Decreased red blood cells, hemoglobin, and hematocrit d Increased blood urea nitrogen (BUN) and serum creatinine levels
D
What mechanism that can trigger SIRS is related to myocardial infarction or pancreatitis? a. abscess formation b. microbial invasion c. global perfusion deficits d. ischemic or necrotic tissue
D
What should the nurse assess the patient for during administration of IV norepinephrine? a. hypotension b. marked diuresis c. metabolic alkalosis d. decreased tissue perfusion
D
When caring for an obtunded ED client with shock of unknown origin, which action should the nurse take first? A. Establish IV access and hang prescribed infusion B. Apply the automatic BP cuff C. Assess level of consciousness and pupil response to light D. Check the airway and respiratory status
D
When caring for client with hypovolemic shock with these assessment findings, T 97.9, P 122, R 24, BP 86/48, total urine output 20mL in last 2 hours, skin cool and clammy, which of the following orders would the nurse question? A. Dopamine (Intropin) 12mcg/kg/min B. Dobutamine (Dobutrex) 5mcg/kg/min C. Plasmanate 1 unit D. Bumetanide (Bumex) 1mg IV
D
When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize? a.) Intensity of peripheral pulses and body temperature. b.) Peripheral pulses and heart rate (HR). c.) Metabolic alkalosis and oxygen saturation. d.) Cardiac output (CO) and blood pressure (BP).
D
Which hematologic problem most significantly increases the risks associated with pulmonary artery (PA) catheter insertion? a Leukocytosis b Hypovolemia c Hemolytic anemia d Thrombocytopenia
D
Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? A. Oxygen saturation remains unchanged. B. Core body temperature has increased to 99° F (37.2° C). C. The client correctly states the month and year. D. Serum lactate and serum potassium levels are declining.
D
Which of the following indicate early sepsis, which has an excellent recovery rate if treated promptly? A. Localized erythema and edema B. Low-grade fever & low white blood cell count C. Low oxygen saturation & decreased cognition D. Reduced urinary output & increased respiratory rate
D
Which problem places the client at highest risk for septic shock? A. Stage III Chronic Kidney Disease B. Cirrhosis C. Lung cancer D. 40% burn injury
D
A 70 year old patient is malnourished, has a history of type 2 DM, and is admitted from the nursing home with pneumonia and tachypnea. For which kind of shock should the nurse closely monitor this patient? a. septic shock b. neurogenic shock c. cardiogenic shock d. anaphylactic shock
a
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. attach a cardiac monitor. c. obtain the blood pressure. d. check the level of consciousness.
a
A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr .b. Infuse drotrecogin-a (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.
a
A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c Administer hydrocortisone (SoluCortef) 100 mg IV. d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.
a
A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg .d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
a
Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine? a. The patients central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min. d. The patient has had no urine output since being admitted.
a
The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? a. The patients IV infusion site is cool and pale. b. The patient has warm, dry skin on the extremities. c. The patient has an apical pulse rate of 58 beats/min. d. The patients urine output has been 28 mL over the last hour.
a
When caring for a patient in cardiogenic shock, the nurse recognizes that the metabolic demands of turning and moving the patient exceed the oxygen supply when what change is revealed in hemodynamic monitoring? a. SvO2 from 62% to 54% b. CO from 4.2 L/min to 4.8 L/min c. Stroke volume from 52 to 68 mL/beat d. SVR from 1300 dyne/sec/cm to 1120 dyne/sec/cm
a
Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patients serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient has crackles throughout both lung fields. d. The patients extremities are cool and pulses are weak.
a
A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take? (Select all that apply) a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. d. Administer large volumes of lactated Ringers solution. e. Administer high-flow oxygen (100%) by non-rebreather mask.
a, b, c, e
In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates α-adrenergic stimulation? (Select all that apply) a. skin b. brain c. heart d. kidneys e. gastrointestinal tract
a, d, e
A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate a. infusion of 5% human albumin. b. administration of furosemide (Lasix) IV. c. titration of an epinephrine (Adrenalin) drip. d. administration of hydrocortisone (SoluCortef).
b
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? A. Increased serum albumin B. Decreased respiratory compliance C. Increased gastrointestinal (GI) motility D. Decreased blood urea nitrogen (BUN)/creatinine ratio
b
When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a. Increased serum albumin b. Decreased respiratory compliance c. Increased gastrointestinal (GI) motility d. Decreased blood urea nitrogen (BUN)/creatinine ratio
b
When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? a. BP 92/56 mm Hg b. Skin cool and clammy c. Apical pulse 118 beats/min d. Arterial oxygen saturation 91%
b
When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective? a. No heart murmur is audible. b. Skin is warm, pink, and dry. c. Troponin level is decreased. d. Blood pressure is 90/40 mm Hg.
b
Which information about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the heath care provider? a. The patients heart rate is 108 beats/min. b. The patient is complaining of chest pain. c. The patients peripheral pulses are weak. d. The patients urine output is 15 mL/hr.
b
Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.
b
A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.
b. Drink fluids on a regular schedule.
The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain a. 500 mL of 5% albumin. b. lactated Ringers solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.
c
When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Decreasing the room temperature to 68 F for a patient with neurogenic shock d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
c
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Avoid elevating head of bed. b. Check temperature every 2 hours .c. Monitor breath sounds frequently. d. Assess skin for flushing and itching.
c
The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? a Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds b Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin c PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites d Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL
c PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites
A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first? a. Place the patient on continuous cardiac monitor. b. Draw blood to type and crossmatch for transfusions. c. Insert two 14-gauge IV catheters in antecubital space. d. Administer oxygen at 100% per non-rebreather mask.
d
A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion .b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion. d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.
d
After coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care? a . Cardiac index (CI) of 5 L/min/m2 b. Central venous pressure of 8 mm Hg c. Mean arterial pressure (MAP) of 86 mm Hg d. Pulmonary artery pressure (PAP) of 28/14 mm Hg
d
During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation
d
What laboratory finding is consistent with a medical diagnosis of cardiogenic shock? a. Decreased liver enzymes b. Increased white blood cells c. Decreased red blood cells, hemoglobin, and hematocrit d. Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels
d
Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation
d
