Chapter 8

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%

ANS: 1 A CVP reading of 8 mm Hg is within normal range and rehydration has been restored.

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

ANS: 1 Acute pericarditis and the development of fluid accumulation in the pericardial space can lead to the development of obstructive shock.

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

ANS: 1 An expected action for epinephrine is bronchodilation as evidenced by less wheezing.

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

ANS: 1 Cardiac tamponade can lead to obstructive shock.

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 term-22 3. Tachycardia 4. Oliguria

ANS: 1 Chest pain is a symptom associated with a massive pulmonary embolus.

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.

ANS: 1 In an anaphylactic reaction leading to distributive shock, the release of histamine causes vasodilation with plasma leakage. Vasodilation leads to profound hypotension, hypovolemia from fluid extravasation, reduced reload, and reduced cardiac output.

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

ANS: 1 In cardiogenic shock, cardiac output is reduced, leading to poor tissue perfusion

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

ANS: 1 Jugular vein distention is a manifestation of cardiogenic shock.

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

ANS: 1 One etiology of cardiogenic shock is a myocardial infarction.

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.

ANS: 1 The dose of 0.03 units/min is usually added to a norepinephrine infusion.

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

ANS: 1 The expected effect of this medication is an increase in blood pressure.

The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings? Standard Text: Select all that apply. 1. Age 80 2. History of atrial fibrillation 3. Bacteremia 4. T3 spinal cord injury 5. Latex allergy

ANS: 1, 2 Rationale 1: Advanced age increases the risk for development of pulmonary emboli, which is one cause of obstructive shock. Rationale 2: Atrial fibrillation increases the risk for developing pulmonary emboli, which is one cause of obstructive shock.

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? 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

ANS: 1, 2, 3 Rationale 1: At high doses of norepinephrine, decreased peripheral pulses indicates significant vasoconstriction. Rationale 2: At high doses of norepinephrine, a drop in body temperature indicates significant vasoconstriction. Rationale 3: At high doses of norepinephrine, paresthesias indicate significant vasoconstriction.

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? 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.

ANS: 1, 2, 3 Rationale 1: Epinephrine produces bronchodilation, improving the respiratory status. The route of administration is initially intramuscular. Rationale 2: Supplemental oxygen is used in the treatment of anaphylactic shock. Rationale 3: Hydrogen ion blockers such as diphenhydramine may be administered to block the histamine effects.

During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? 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

ANS: 1, 2, 3 Rationale 1: Hypotension is a manifestation of cardiogenic shock. Rationale 2: Delayed capillary refill is a manifestation of cardiogenic shock. Rationale 3: Crackles are a manifestation of cardiogenic shock.

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? Standard Text: Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations

ANS: 1, 2, 3 Rationale 1: Hypotension is a manifestation of neurogenic shock because of the loss of autonomic reflexes. Rationale 2: Bradycardia occurs because of the loss of sympathetic innervation. Rationale 3: Warm dry skin occurs because of a loss of cutaneous control of sweat glands.

A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies? Standard Text: Select all that apply. 1. Sepsis 2. Spinal cord injury 3. Anaphylaxis 4. Hemorrhage 5. Pulmonary embolism

ANS: 1, 2, 3 Rationale 1: One etiology of distributive shock is sepsis. Rationale 2: One etiology of distributive shock is spinal cord injury. Rationale 3: One etiology of distributive shock is anaphylaxis.

A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? 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

ANS: 1, 2, 3 Rationale 1: This finding is consistent with pulmonary vascular congestion. Rationale 2: This finding is consistent with fluid volume overload. Rationale 3: This finding is consistent with pulmonary vascular congestion.

A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? 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

ANS: 1, 2, 3, 4 Rationale 1: Venoms such as bee stings can trigger anaphylactic shock. Rationale 2: Drugs can trigger anaphylactic shock. Rationale 3: Latex can trigger anaphylactic shock. Rationale 4: Contrast media for diagnostic tests can trigger anaphylactic shock.

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.

ANS: 1, 2, 3, 4, 5 , 6 Rationale 1: The obstruction caused by the pulmonary embolism increases the afterload of the right ventricle, causing right ventricular failure. Rationale 2: The embolus prevents adequate blood flow from the pulmonary circulation to the left ventricle. Rationale 3: Because blood flow from the pulmonary circulation is blocked, left ventricular preload drops. Rationale 4: Because left ventricular preload is decreased, there is not enough blood in the heart to pump, causing decreased cardiac output. Rationale 5: A lack of blood circulating will lead to hypotension. Rationale 6: When the blood is backed up and is not being pumped into the general circulation, tissue perfusion is reduced.

The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient?Standard Text: Select all that apply. 1. Dopamine 2. Norepinephrine 3. Dobutamine 4. Epinephrine 5. Phenylephrine

ANS: 1, 2, 3, 5 Rationale 1: Dopamine is commonly used in the treatment of cardiogenic shock. Rationale 2: Norepinephrine is commonly used in the treatment of cardiogenic shock. Rationale 3: Dobutamine may be used in the patient with cardiogenic shock who has an adequate blood pressure. Rationale 5: Phenylephrine is a vasopressor and may be used in the patient with cardiogenic shock who is receiving dobutamine.

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

ANS: 2 Hypothermia can result when providing room temperature fluids at a faster pace than the body can warm them.

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

ANS: 2 In cardiogenic shock, there is a low cardiac output, hypotension, and pulmonary edema.

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

ANS: 2 Increased peripheral resistance causes the blood supply to decrease and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply.

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%

ANS: 2 Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion.

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

ANS: 2 The patient requires immediate infusion of an adequate amount of fluid. Fluid resuscitation begins with 500 to 1,000 mL of an isotonic solution.

Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Standard Text: Select all that apply. 1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema

ANS: 2, 3 Rationale 2: Renal insufficiency is a serious complication because of the prerenal etiology of hypovolemia. Rationale 3: Early identification and correction of the fluid volume deficit in hypovolemic shock is necessary to prevent cerebral ischemia.

What will the nurse identify as symptoms of hypovolemic shock in a patient? 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

ANS: 2, 3, 4 Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status. Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock. Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced.

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

ANS: 3 Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume.

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)

ANS: 3 Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock.

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.

ANS: 4 Bradycardia in neurogenic shock is corrected by the administration of atropine at the dose of 0.5 to 1.0 mg intravenous every 5 minutes to a total dose of 3 mg.

A patient weighing 220 lbs is prescribed 10 mcg/kg/min of dopamine to improve cardiac output from cardiogenic shock. How many milligrams of dopamine will the patient receive in an hour?

ANS: 60 Determine the patient's weight in kg by dividing 220 lbs by 2.2 or 100 kg. Then multiply the number of mcg of medication the patient is to receive per minute by 100 kg or 10 mcg × 100 kg = 1,000 mcg. This is the dosage the patient will receive in 1 minute. To determine the amount of medication in 1 hour, multiply 1,000 mcg × 60 = 60,000 mcg. Using the conversion 1 mg = 1,000 mcg, divide 60,000 mcg by 1,000 mcg to determine that the patient will receive 60 mg of dopamine in 1 hour.