CH 37
The client with which problem is at highest risk for hypovolemic shock? Esophageal varices Kidney failure Arthritis and daily acetaminophen use Kidney stone
A.
The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do? Compare these vital signs with the last several readings. Request that the surgeon see the client. Increase the rate of intravenous fluids. Reassess vital signs using different equipment.
A.
How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? Urine output 20 to 30 mL/hr for the last 4 hours Mean arterial pressure (MAP) 70 mm Hg Albumin 3.5 g/dL Hemoglobin 7.6 g/dL
B.
Which problem places a client at highest risk for sepsis? Pernicious anemia Pericarditis Post kidney transplant Client owns an iguana
C.
The client in shock has the following vital signs: T 99.8° F, P 132 beats/min, R 32 breaths/min, and BP 80/58 mm Hg. Calculate the pulse pressure. __________________
1.22 MM/HG
A client with septic shock is to receive dopamine at 18 mcg/kg/min. The clients weight is 154 pounds. How many mcg/min does the nurse administer?
1260 MCG/MIN
A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? (Select all that apply.) Ask family members to stay with the client. Call the health care provider. Increase IV and oxygen rates. Remain with the client. Reassure the client that everything is being done for him or her.
A.D.E.
Which clients are at immediate risk for hypovolemic shock? (Select all that apply.) Unrestrained client in motor vehicle accident Construction worker Athlete Surgical intensive care client 85-year-old with gastrointestinal virus
A.D.E.
A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? Hourly urine output 10 to 12 mL/hr Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg Blood glucose 245 mg/dL Serum creatinine 3.6 mg/dL
B.
A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? Obtain vital signs every 15 minutes. Measure hourly urine output. Check oxygen saturation. Assess level of alertness.
B.
The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider? Admission to rehabilitation hospital for ambulatory retraining Collaboration with home care agency for return to home Discussion with family and provider regarding palliative care Enrollment in a cardiac transplantation program
C.
What typical sign/symptom indicates the early stage of septic shock? Pallor and cool skin Blood pressure 84/50 mm Hg Tachypnea and tachycardia Respiratory acidosis
C.
A client with hypovolemic shock has these vital signs: temperature 97.9° F; pulse 122 beats/min; blood pressure 86/48 mm Hg; respirations 24 breaths/min; urine output 20 mL for last 2 hours; skin cool and clammy. Which medication order for this client does the nurse question? Dopamine (Intropin) 12 mcg/kg/min Dobutamine (Dobutrex) 5 mcg/kg/min Plasmanate 1 unit Bumetanide (Bumex) 1 mg IV
D.
Which problem places a person at highest risk for septic shock? Kidney failure Cirrhosis Lung cancer 40% burn injury
D.
A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? Broad-spectrum antibiotics Blood transfusion Cooling baths NPO status
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? Temperature Pulse Respiration Blood pressure
A.
The client with which laboratory result is at risk for hemorrhagic shock? International normalized ratio (INR) 7.9 Partial thromboplastin time (PTT) 12.5 seconds Platelets 170,000/mm3 Hemoglobin 8.2 g/dL
A.
The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: PHYSICAL ASSESSMENT FINDINGS: 1. PULSE 140BPM AND THREADY 2. BP 60/40 3. RR 40/MIN AND SHALLOW DIAGNOSTIC FINDINGS: ABG=REPS ACID, LACTATE LEVEL OF 7 All of these provider prescriptions are given for the client. Which does the nurse carry out first? Notify anesthesia for endotracheal intubation. Give Plasmanate 1 unit now. Give normal saline solution 250 mL/hr. Type and crossmatch for 4 units of packed red blood cells (PRBCs).
A.
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? Hypotension Bradypnea Heart blocks Tachycardia
D.
When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? Obtain IV access and hang prescribed fluid infusions. Apply the automatic blood pressure cuff. Assess level of consciousness and pupil reaction to light. Check the airway and respiratory status.
D.
Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? The LPN/LVN who has 20 years of experience The new RN who recently finished orienting and is working independently with moderately complex clients The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago The RN with 2 years of experience in intensive care
D.
How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? PaCO2 58 mm Hg Lactate 9.0 mmol/L Partial thromboplastin time 64 seconds Potassium 2.8 mEq/L
B.
The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? Administer the antibiotic immediately. Ensure that blood cultures were drawn. Obtain signature for informed consent. Take the client's vital signs.
B.
Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? Localized erythema and edema Low-grade fever and mild hypotension Low oxygen saturation rate and decreased cognition Reduced urinary output and increased respiratory rate
B.
Which laboratory result is seen in late sepsis? Decreased serum lactate Decreased segmented neutrophil count Increased numbers of monocytes Increased platelet count
B.
Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? Client receiving a blood transfusion Client with severe ascites Client with myocardial infarction Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion
B.