Chapter 11 Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? - Compensatory - Irreversible - Precompensatory - Progressive

Irreversible Rationale: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? - It slows the proliferation of bacteria and viruses during shock - It decreases the energy expanded through the functioning of the GI system - It assists in expanding the intravascular volume of the body - It promotes GI function through direct exposure to nutrients

It promotes GI function through direct exposure to nutrients Rationale: Parenteral or enteral nutrition support should be initiated as soon as possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complication associated with parenteral feeding.

A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.

B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. Rationale: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells do not have an adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, not not all, all types of shock.

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 - Plasma - Dextran - Packed red blood cells - Salt-poor albumin

Dextran Rationale: Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

A critical nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply. - Hypovolemia - Difficulty breathing - Cardiovascular overload - Pulmonary edema - Hypoglycemia

Difficulty breathing* Cardiovascular overload* Pulmonary edema

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? - Distributive - Hypovolemic - Obstructive - Carcinogenic

Distributive Rationale: Three types of distributive shock are neurogenic, septic, and anaphylactic shock.

A patient is diagnosed with cardiogenic shock. Which medication will the RN expect to be prescribed? - Dopamine - Dobutamine - Desmopressin - Diazepam

Dobutamine Rationale: Dobutamine is a medication used to improve contractility and is the drug of choice for cardiogenic shock. Dopamine, desmopressin, and diazepam are not indicated for improving contractility.

The nurse is caring for a client in ICU unit whose condition is deteriorating. The nurse received orders to initiate an infusion of dopamine, Which assessments and interventions should the nurse prioritize? - Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration - Reviewing medications, performing a focused cardiovascular assessment and providing client education - Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema. - Routine monitoring for vital signs, monitoring the peripheral intravenous site, and providing early discharge instructions

Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration Rationale: Dopamine is a sympathomimetic agent that has varying vasoactive effects on the dosage. When vasoactive medications are given, vital signs must be monitored frequently (at least every 15 min until stable or more often if indicated), not "routinely." Vasoactive medications should be given through a central, not peripheral, venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. High doses can cause vasoconstriction, which increases afterload and thus increases cardiac workload. This effect is undesirable in cardiogenic shock therefore, doses must be carefully titrated.

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? - Give PRN furosemide (Lasix) 40 mg IV - Increase normal saline infusion to 250 mL/hr - Administer hydrocortisone (Solu-Cortef) 100 mg IV - Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

Give PRN furosemide (Lasix) 40 mg IV Rationale: Furosemide will further lower the filling pressures and renal perfusion for a patient with septic shock. The other orders are appropriate.Pressure in the right atrium is CVP. A more vigorous heart contraction leads to a low CVP.PAWP represents the preload of the left ventricle.

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? - Monito urine output every hour - Administer oxygen by nasal cannula at 3 l/min - Draw samples for hemoglobin and hematocrit every 6 hours - Infuse IV fluids at 83 ml/hour

Infuse IV fluids at 83 ml/hour Rationale: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.

The nurse in the ICU is caring for a 47-year-old obese client who is in shock following a mva. What would be the mai challenge in meeting this client's elevated energy requirements during prolonged rehabilitation? - Loss of adipose tissue - Loss of skeletal muscle - Inability to convert adipose tissue to energy - Inability to maintain normal body mass

Loss of skeletal muscle Rationale: Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the client has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the client's recovery time.

The nurse in a rural nursing facility will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after giving borth at home. Which principle should guide the nurse's administration of IV fluid? - 5% albumin is preferred because it is inexpensive and is always readily available. - Dextran should be given because it increases intravascular volume and counteracts coagulopathy - Whatever fluid is readily available in the clinic should be given, due to the nature of the emergency - LR solution is ideal because it increases volume, buffers acidosis, and is the best choice for clients with liver failure

Whatever fluid is readily available in the clinic should be given, due to the nature of the emergency Rationale: The best fluid to treat shock remains controversial. In emergencies, the "best" fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids, such as dextran and albumin, should be used; however, with. crystalloids, more fluid is necessary to restore intravascular volume. Albumin is very expensive and is a blood product so it is not always readily available for use. Dextran does increase intravascular volume, but t increases the risk for coagulopathy. LR is a goo solution because it increases volume and buffers acidosis, but it should not be used in clients with liver failure because the liver is unable to convert lactate to bicarbonate.

The nurse provides care for a client who is diagnosed with shock and who is at risk for multiple organ dysfunction syndrome (MODS). Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of ... as evidenced by ... - hepatic dysfunction, left-sided weakness - acute lung injury, shortness of breath - hyper-metabolic state, an increase in heart rate - renal dysfunction, a drop in blood pressure

acute lung injury, shortness of breath Rationale: In multiple organ dysfunction syndrome (MODS), the sequence of organ dysfunction varies depending on the client's primary illness and comorbidities before experiencing shock; however, the lungs are often the first organ to show dysfunction. The client who is at risk for MODS should be assessed for the first symptom that often accompanies this diagnosis, which is acute lung injury (ALI). Symptoms associated with ALI include shortness of breath (i.e., dyspnea) and respiratory failure. Although the first presentation of MODS is often ALI, the client is also at risk for developing a hypermetabolic state, hepatic dysfunction, and renal dysfunction. Although the client may experience a drop in blood pressure and an increased heart rate with MODS, the heart and circulatory system are not affected first by this diagnosis. Left-sided weakness is associated with a right-sided stroke and not MODS.

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? - Auscultate bowel sounds - Palpate for abdominal pain - Ask the patient about nausea - Check stools for occult blood.

Check stools for occult blood. Rationale: Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration.

Colloids and Crystalloids

Commonly used are: Colloids: Albumin Crystalloids: 0.9% sodium chloride and Lactated ringer - The lactate ion is converted to bicarbonate, which helps buffer the overall acidosis that occurs in shock. - When administering large volumes of crystalloid solutions, the nurse must monitor the lungs for adventitious sounds, s/s of interstitial edema, work of breathing (i.e., increasing effort required for the patient to breathe, depth of breathing, respiratory rate), and changes in oxygen saturation.

A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the ICU nurse include during this phase of the client's care? - Communicate clearly and frequently with the client's family - Taper down interventions slowly when he prognosis worsens - Transfer the client to subacute unit when recovery appears unlikely - Ask the client's family how they would prefer treatment to proceed

Communicate clearly and frequently with the client's family Rationale: As it becomes obvious that the client is unlikely to survive, the family must be formed about the prognosis and likely outcome. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The client could notbe transferred to a subacute unit

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? - Initial stage - Progressive stage - Compensatory stage - Irreversible stage

Compensatory stage Rationale: In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal 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: - Decrease heart rate - Constrict blood vessels in the cardiorespiratory system - Vasodilate the skeletal muscles - Relax the bronchioles

Constrict blood vessels in the cardiorespiratory system Rationale: Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

Stages of Shock

- Compensated - Progressive (Decompensated) - Irreversible

The ICU nurse is responsible for the care of a client who is in shock. What cardiac S?S would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. - Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines - Hypotension that responds to bolus fluid resuscitation - Exaggerated response to vasoactive medications - Serum lactate greater than 4 mmol/L - Mean arterial pressure of less than 65 mm Hg

- Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines - Serum lactate greater than 4 mmol/L - Mean arterial pressure of less than 65 mm Hg

Treatment - Surviving Sepsis Bundle

- Labs: Blood cultures from two sites and a lactate level - Administer bread-spectrum antibiotics - Switch to specific antibiotic based ob blood cultures results - Reapid administration of 30 ml/kg of crystalloid fluid to keep MAP > 65 mm Hg Vasopressors if needed

Which are interprofessional goals of treating sepsis? Select all that apply. - Prevent and treat infection. - Maintain tissue oxygenation. - Avoid nutritional support. - Support failing organs. - Keep mean arterial pressure (MAP) above 65 mm Hg.

- Prevent and treat infection. - Maintain tissue oxygenation. - Support failing organs. - Keep mean arterial pressure (MAP) above 65 mm Hg.

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? - C-spine x rays - 100% oxygen via nonrebreather mask - Two large-bore IVs and begin crystalloid fluids - Type and cross match

100% oxygen via nonrebreather mask Rationale: The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied via a nonrebreather mask. The other orders should be completed after the client's airway is secure.

A nurse is performing glucose checks for a client in the progressive stage of shock. What glucose range would the nurse expect to see for the best outcome with the client? - 60 mg/dl - 100 mg/dl - 120 mg/dl - 180 mg/dl

180 mg/dl Rationale: Tight glycemic control (serum glucose of 80 to 100 mg/dL) is no longer recommended, as hypoglycemic events associated with regulating tight control in critically ill clients have been found to result in adverse patient outcomes. Current evidence suggests that maintaining serum glucose levels lower than 180 mg/dL with insulin therapy and close monitoring is indicated in the management of the critically ill client.

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? - 60% - 50% - 70% - 40%

70% Rationale: Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.

The nurse is administering colloids to a client during the first 6 hours of septic shock. What is the client's central venous pressure reading goal? 6 to 7 mm Hg 4 to 5 mm Hg 1 to 3 mm Hg 8 to 12 mm Hg

8 to 12 mm Hg Rationale: The goal in colloidal fluid replacement is to achieve a central venous pressure of 8 to 12 mm Hg or higher (normal = 2 to 8 mm Hg).

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers - A full liquid diet - Isotonic enteral nutrition every 6 hours - An infusion of crystalloids at an increased rate of flow - A continuous infusion of total parenteral nutrition

A continuous infusion of total parenteral nutrition Rationale: Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.

Which patient is at the highest risk for developing sepsis? - A patient admitted for nephrolithiasis - A patient admitted for end-stage kidney disease - A patient admitted for vaginal delivery of a child - A patient who is newly nothing-by-mouth (NPO) status for a procedure in the morning

A patient admitted for end-stage kidney disease Rationale: People who are immunocompromised, older adults, have chronic illnesses, or have undergone invasive procedures and emergent and/or multiple surgeries are at the highest risk for developing sepsis. In this group, the patient admitted for end-stage kidney disease is at a higher risk than the patient with nephrolithiasis, the patient giving birth, or the patient who is awaiting a procedure.

Which of the following is a clinical characteristic of neurogenic shock? - Cool skin - Bradycardia - Tachycardia - Moist skin

Bradycardia Rationale: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

The ICU nurse is caring for a client in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the client? - Anaphylaxis - Decreased oxygen consumption - Abdominal compartment syndrome - Decreased serum osmolality

Abdominal compartment syndrome Rationale: Abdominal compartment syndrome is a serious complication that may occur when large volumes of fluid are given

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 - Re-assesses the vital signs - Calls the Rapid Response team - Administers oxygen by nasal cannula at 2 liters per minute - Contacts the admitting phhysician

Administers oxygen by nasal cannula at 2 liters per minute Rationale: The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

A patient is diagnosed with hypovolemic shock. What does the nurse anticipate being included in the plan of care? - Administration of broad-spectrum antibiotics - Administration of blood products and intravenous fluids - Administration of vitamin K - Administration of protamine sulfate

Administration of blood products and intravenous fluids Rationale: Hypovolemic shock requires blood products and/or fluids. Antibiotics are indicated for septic shock, and vitamin K and protamine sulfate are antidotes for warfarin and heparin. They will not help unless anticoagulants are the cause.

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 - Troponin levels less than 0.35 ng/mol - Adventitious breath sounds - A change in apical pulse rate from 102 to 88 beats/min - Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute

Adventitious breath sounds Rationale: The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.

The nurse in the ED is caring for a client recently admitted with a likely MI. The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at an increased risk for MI due to which factor? - Arrhythmias - Elevated BNP - Use of thrombolytics - Dehydration

Arrhythmias Rationale: Cardiogenic shock occurs when the heart's ability to pump bood is impaired and the supply of oxygen is inadequate for the heart and tissues. An elevated BNP is noted after an MI has occurred and does not increase risk.

The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention? -Reviewing the cause of shock and prioritizing the client's psychosocial needs - Assessing and understanding shock and the significant changes in assessment data to guide the plan of care - Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive - Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock

Assessing and understanding shock and the significant changes in assessment data to guide the plan of care Rationale: Nursing care of clients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data.

An adult client has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this client. What aspect of the care should be prioritized by the home health nurse? - Providing supervision to home health aides in providing necessary client care - Assisting the client and family to identify and mobilize community resources - Providing ongoing medical care during the family's rehabilitation phase - Reinforcing the importance of continuous assessment with the family

Assisting the client and family to identify and mobilize community resources

Which is not a potential source of an infection that could cause sepsis? - Central venous access device - Atherosclerosis - COVID-19 - Stage 4 pressure injury

Atherosclerosis

What is happening in the compensatory stage of shock? - The organs are failing and death is imminent. - The heart is unable to meet oxygen demands. - Blood is being shunted to vital organs to maintain nearly normal vital signs. - The patient is asymptomatic but basic cellular changes have started.

Blood is being shunted to vital organs to maintain nearly normal vital signs. Rationale: During the compensatory stage of shock, the sympathetic nervous system is stimulated, and the body experiences the fight-or-flight response. The body shunts blood to vital organs, including the heart, brain, and lungs. Blood pressure and heart rate may be normal or show subtle changes. Organs fail during the irreversible stage. The heart is unable to meet oxygen demands during the progressive stage. The patient is asymptomatic with basic cellular changes during the initial stage.

The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with he early stage of compensation? - Increased urine output - Decreased heart rate - Hyperactive bowel sounds - Cool, clammy skin

Cool, clammy skin Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client's skin is cool and clammy. Also in this compesatory stage

At what point in shock does metabolic acidosis occur? - Late - Irreversible - Decompensation (Progressive) - Early)

Decompensation (Progressive) Rationale: The decompensation or progressive stage occurs as compensatory mechanisms fail. The client's condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.

What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? - Decreased blood pressure - Increased cardiac output - Reduced preload - Reduced afterload

Decreased blood pressure Rationale: A potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently according to the manufacturer's recommendation and institutional policy.

The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that ADH plays a significant role in this health problem. What assessment finding will the murse likely observe related to the role of ADH hormone played during hypovolemic shock? - Increased hunger - Decreased thirst - Decreased urinary output - Increased capillary perfusion

Decreased urinary output Rationale: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further retain water in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increases fluid volume; and capillary perfusion decreases as the body shunts blood away from the periphery and to the vital organs.

A critical care is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock? - Agressive hypoglycemic control - Administration of of hypertonic IV fluids - Early provision of nutritional support -Aggressive antibiotic therapy

Early provision of nutritional support Rationale: Nutritional support is necessary for all clients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many clients.

A client who experienced shock is now non-responsive 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 and talk to the client - Inform the family that everything is being done to assist with the client's survival - Open up discussion among the family members about nursing home placement - Contact a spiritual advisor to provide comfort to the family

Encourage the family and talk to the client Rationale: The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? - Fluid volume circulating in the blood vessels decreases - There is an uncontrolled increase in cardiac output - Blood pressure regulation becomes irregular - The client experiences tachycardia and a bounding pulse

Fluid volume circulating in the blood vessels decreases Rationale: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? - Shock begins in the decompensation stage - In the compensation stage, catecholamines are released - Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage - The renin-angiotensin-aldosterone system fails in the compensation stage

In the compensation stage, catecholamines are released Rationale: Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage.

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? - Increase the rate for the dopamine (Intropin) infusion - Decrease the rate for the nitroglycerin (Tridil) infusion - Increase the rate for the sodium nitroprusside (Nipride) infusion - Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

Increase the rate for the sodium nitroprusside (Nipride) infusion Rationale: Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

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 - Dextran - 0.9% sodium chloride - Albumin

Lactated Ringer's Rationale: Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered? - Dobutrex - Methotrexate - Nipride - Levophed

Levophed Vasoactive medications should never be stopped abruptly, because this could cause severe hemodynamic instability, perpetuating the shock state.

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? - Semi-Fowler's - Supine - Modified trendelburg - Trendelburg

Modified trendelburg Rationale: The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.

A nurse in the intensive care unit receives a report from the nurse in the emergency department about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing? - Anaphylactic shock - Neurogenic shock - Septic shock - Hypovolemic shock

Neurogenic shock Rationale: Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation.

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? - Heart rate - Orientation - Blood pressure - Oxygen saturation

Oxygen saturation Rationale: Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as - Progressive - Neurogenic - Compensatory - Hypovolemic

Progressive Rationale: The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin.

The ICU nurse is caring for an acutely ill client with signs of multiple organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing MODS due to all of the following EXCEPT: - Malnutrition - Advanced age - MUltiple comorbidities - Progressive dyspnea

Progressive dyspnea Rationale: The client with advanced age is at risk for developing MODS due to the lack of physiological reserve. The client with malnutrition metabolic compromise and the client with multiple comorbidities is at risk for developing MODS due to decreased organ function. Progressive dyspnea is the fist sign pf MODS

The nurse is caring for a client in the compensation stage of shock. The nurse knows 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? - Increases the production of antidiuretic hormone - Decreases peripheral blood flow - Restores blood pressure - Increases catecholamines secretion

Restores blood pressure Rationale: The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone.

A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse - Raises the foot of the client's bed - Elevated the head of the client's bed - Places the client in a Trendelburg position - Turns the client to a s-de-lying position

Raises the foot of the client's bed Rationale: The description of the client is that of a person experiencing shock. In addition to administering fluids to a client in shock, the nurse positions the client with the legs elevated, which promotes venous blood return. Elevating the head of the bed will cause the client's blood pressure to drop even more. The Trendelenburg position will make breathing difficult and does not increase blood pressure or cardiac output. Placing the client in a side-lying position does not increase venous blood return.

The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock? - Elevated systolic blood pressure - Elevated mean arterial pressure (MAP) - Shallow, rapid respirations - Bradycardia

Shallow, rapid respirations Rationale: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have a tachycardia as a symptoms. Infection can lead to septic shock.

The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanisms will increase the client's cardiac output during the hypovolemic state? - Third spacing of fluid - Dysrhythmias - Tachycardia - Gastric hyper-motility

Tachycardia

Which description best characterizes sepsis? - A localized infection - An infection that spread from the skin to the lymph nodes - The body's exaggerated response to infection - An infection that develops postoperatively

The body's exaggerated response to infection Rationale: Sepsis is the body's extreme response to infection. It affects the full body and is not localized. It affects more than the skin and lymph nodes and while it can develop postoperatively, it can also develop due to other reasons.

The nurse in ICU is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion? - The client is in the compensatory stage of shock - The client is in the progressive stage of shock - The client will stabilize and be released by tomorrow - The client is in the irreversible stage of shock

The client is in the compensatory stage of shock Rationale: In the compensatory stage of shock, the blood pressure remains wnl. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Clients display the often described "flight or fight" response. The body shunts blood from organs such as the skin , kidneys, and GI to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. If the client were in irreversible stage of shock, his blood pressure would be very low and his organs would be failing.

A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planing during the administration of a vasoactive drug? - The drug should be discontinued immediately after blood pressure increases - The drug dose should be tapered down once vital signs improve - The client should have arterial blood gases drawn every 10 minutes during treatment - The infusion rate should be titrated according to the client's subjective sensation of adequate perfusion

The drug dose should be tapered down once vital signs improve Rationale: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynmic instability, perpetuating the shoc state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but draws every 10 minutes are not the norm.

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 is having a reaction to the vasoconstricting medications - The patient has bleeding esophageal varices - The patient has a tumor in the esophagus - The patient has developed a stress ulcer that is bleeding

The patient has developed a stress ulcer that is bleeding. Rationale: GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus.

A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing? - anaphylactic - cardiogenic - neurogenic - hypovolemic

neurogenic Rationale: Neurogenic shock can be caused by spinal cord injury, spinal anesthesia, or other nervous system damage; client symptoms include dry skin and bradycardia with hypotension. Cardiogenic shock is seen in clients with impaired heart function. Hypovolemic shock is caused by decreased intravascular volume. Anaphylactic shock is caused by a severe allergic reaction; clients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen-antibody reaction; specifically, an immunoglobulin E-mediated response.

A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply. - phenylephrine - norepinephrine - vasopressin - epinephrine - milrinone

norepinephrine* epinephrine* vasopressin* phenylephrine Rationale: The vasopressive agents that may be used in managing a client with cardiogenic shock include norepinephrine (Levophed), vasopressin (Pitressin), and phenylephrine (Neo-Synephrine). The vasopressive agents increase blood pressure by constriction. Milrinone (Primacor) is an inotropic agent that improves contractility. Epinephrine is both a vasopressor and an inotropic agent.

The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain - hypothermia blanket - lactated Ringers solution - two 14-gauge IV catheters - dopamine (Intropin) infusion.

two 14-gauge IV catheters Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringers solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

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. - Administer intravenous fluids - Administer prophylactic packed red blood cells - Monitor for changes in vital signs - Identify the cause of shock - Administer vasoconstrictive medications

- Identify the cause of shock - Administer intravenous fluids - Monitor for changes in vital signs Rationale: Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.

A fluid bolus should never be given rapidly, because rapid fluid administration in patients with cardiac failure may result in acute pulmonary edema.

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A nurse is assessing a client who is experiencing significant stress due to septicemia. The nurse should...

-Administer oxygen therapy - Monitor temperature - Obtain the lactate level Rationale: The nurse should expect to administer oxygen therapy to support perfusion, monitor temperature to assess metabolic response, and obtain lactate levels, which serve as a critical predictor of the client's metabolic stress response. The nurse should not place a client with septicemia in a prone position because this would lead to further respiratory compromise. The nurse should not increase PO fluid intake because this would also lead to respiratory compromise and fluid volume overload.

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? - Initiate enteral feedings as prescribed - Begin a continuous infusion of insulin per protocol - Administer norepinephrine as prescribed - Administer recombinant human activated protein C (rhAPC) as prescribed

Administer norepinephrine as prescribed Rationale: Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.

A client presents to the emergency department with her spouse. The client appears to be in respiratory distress. The spouse states, "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which agent first? - Epinephrine intramuscularly - Diphenhydramine IV - IV infusion of normal saline - Albuterol nebulizer

Epinephrine intramuscularly Rationale: All of the interventions are indicated in the treatment of anaphylactic shock. However, IM epinephrine is administered first because of its vasoconstrictive action. IV Diphenhydramine is administered to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications such as albuterol may be given to reverse histamine-induced bronchospasm. Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability.

A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock? - HR 120 bpm, BP 88/58 mm Hg - Shortness of breath - HR 48 bpm, BP 90/60 mm Hg - Cool, moist skin

HR 48 bpm, BP 90/60 mm Hg Rationale: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. The other signs and symptoms are associated with hypovolemic shock.

The ICU nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that organ damage may be occurring? - Urinary output increases - Skin becomes warm and dry - Adventitious lung sounds occur in the upper airway - Heart and respiratory rates are elevated

Heart and respiratory rates are elevated Rationale: As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the client begins to show signs or organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (eg, aki, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and MODS progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs

The ICU nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of: - increased stroke volume - increased cardiac output - decreased heart rate - decreased venous return

decreased venous return Rationale: Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volune and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? - Check temperature every 2 hours - Monitor breath sounds frequently - Maintain patient in supine position - Assess skin for flushing and itching.

Monitor breath sounds frequently Rationale: Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention? - Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good - Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months - Promoting communication with the client and family along with addressing end-of-life issues - Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

Promoting communication with the client and family along with addressing end-of-life issues Rationale: Promoting communication with the client and family is a critical is a critical role of the nurse with a client in progressive shock. Many cases of MODS result in death, and the life expectancy of clients with MODS is usually measured in hours and possibly days, but not in months.

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. - disseminated intravascular coagulation - hypoglycemia - GERD - kidney failure - acute respiratory distress syndrome

disseminated intravascular coagulation* kidney failure* acute respiratory distress syndrome

The ICU nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs? - Th use of albumin as an energy sources by the body because of the need for increased adenosine triphosphate - The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity - The release of catecholamine that creates an increase in metabolic rate and caloric requirements - The increase in GI peristalsis during shock, and the resulting diarrhea

The release of catecholamine that creates an increase in metabolic rate and caloric requirements Rationale: Nutritional support is an important aspect of care for clients in shock. Clients in shock may require 3.000 calories daily. This calorie need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements.

A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure? - rapid respirations - bradycardia - low urine output - constipation

low urine output Rationale: Tissue perfusion and organ perfusion depend on mean arterial pressure (MAP), or the average pressure at which blood moves through the vasculature. When a MAP falls below 65 mm Hg, a client with progressive shock will have decreased kidney function and low urine output. Clients with low MAP will have tachycardia, slow respirations, and bloody diarrhea.

Which colloid is expensive but rapidly expands plasma volume? - Dextran - Albumin - Lactated Ringer solution - Hypertonic saline

Albumin Rationale: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

An 11-year-old client has been brought to the emergency department by their parent, who reports that the client may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. Which intervention would the nurse prioritize? - Establishing central venous access and beginning fluid resuscitation - Establishing a patent airway and beginning CPR - Establishing peripheral IV access and administering IV epinephrine - Performing a comprehensive assessment and initiating rapid fluid replacement

Establishing a patent airway and beginning CPR Rationale: If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. A patent airway is also an immediate priority.

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? - Unable to measure - Low - High - Normal

Low Rationale: The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.

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? - Myoglobin abd CK-MB - T3 and T4 - BUN and creatinine - Sodium and glucose levels

Sodium and glucose levels

When caring for a client in shock, one of the major nursing golas is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal? - Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping - Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions - Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature - Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment

Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment