CH 14 PrepU
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?
Elevate the legs higher than the heart
Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage?
Albumin
When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?
Myocardial depression
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?
Head injury
You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?
In the compensation stage, catecholamines are released
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
You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family?
The client is not responding to medical interventions
The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately?
The client's heart rate is greater than 90 beats per minute
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
How should vasoactive medications be administered?
Using a central venous line
The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.
Vital signs Skin color Urine output Peripheral pulses
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next
Administers oxygen by nasal cannula at 2 liters per minute
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?
Adrenergic drugs
A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits
Adventitious breath sounds
Which colloid is expensive but rapidly expands plasma volume?
Albumin
A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is
An older adult man with end-stage renal disease and an infected dialysis access site
When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?
Aorta
Which of the following is a clinical characteristic of neurogenic shock?
Bradycardia
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
Older adults with impaired cardiac function are more likely to develop which type of shock?
Cardiogenic shock
You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock?
Circulatory (distributive)
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?
Circulatory (distributive)
The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?
Compensatory stage
The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?
Increase in arterial oxygenation
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
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 Lansoprazole
Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock?
Neurogenic
Which vasodilator medication is used in the treatment of shock?
Nitroglycerin
In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart?
Nitroprusside
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
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?
Intubation and mechanical ventilation
Which stage of shock encompasses 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
The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?
Lactated Ringer's
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 determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?
Narrowed pulse pressure
The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in?
Progressive
Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg?
Progressive
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
A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?
neurogenic shock
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
Which positioning strategy should be used for the client diagnosed with hypovolemic shock?
Modified Trendelenburg
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
A rapid, bounding pulse
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct?
"The client is in shock because the blood volume has decreased in the system."
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
The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?
70%
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers
A continuous infusion of total parenteral nutrition
The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
Arterial blood gas (ABG) findings
What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply.
Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs.
Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:
Blood pressure
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:
Constrict blood vessels in the cardiorespiratory system
What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client?
Decreased blood pressure
A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is
Dextran
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
The nurse is caring for a client with a central venous line in place for the treatment of shock. Which nursing interventions are essential for the nurse to complete in order 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. Apply clean gloves before accessing the line port.
The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation?
Mean arterial pressure of 70 mm Hg
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
Morphine sulfate has which of the following effects on the body?
Reduces preload
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 is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines?
Sodium and glucose levels
When a client is in the compensatory stage of shock, which symptom occurs?
Tachycardia
The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?
The patient has developed a stress ulcer that is bleeding
What is the major clinical use of dobutamine?
increase cardiac output