Hemodynamics Shock, Sepsis

The nurse is caring for a client with systemic inflammatory response syndrome (SIRS) related to bacterial pneumonia. Which interventions would be most appropriate for this client? Select all that apply.

-Electrocardiogram (ECG) monitoring -VTE prophylaxis -Fluid replacement -Antibiotic administration

The nurse caring for a client with sepsis as a result of bacterial pneumonia is monitoring for signs of systemic inflammatory response syndrome (SIRS). Which conditions are indicative of this complication? Select all that apply.

-Fever -Altered mental status -Development of severe hypotension -Development of acute respiratory distress syndrome (ARDS) (The client will have global vasodilation and thus will have decreased blood pressure and perfusion to the other important organs such as the lungs and brain, affecting breathing and mentation.)

A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial pressure (MAP) of 60 mm Hg. Which prescribed intervention would the nurse implement first?

-Increase the rate of intravenous (IV) fluids. (Low CVP hypovolemic)

The nurse is caring for a client admitted for fever and urinary tract infection (UTI) who is at risk for sepsis. What initial intervention would the nurse anticipate?

-Obtaining a urine culture and sensitivity prior to beginning antibiotics

After receiving Situation, Background, Assessment, Recommendation (SBAR) hand-off on a client flagged for sepsis criteria, the nurse would take what action first?

-Perform an assessment of the client and obtain vital signs.

Due to an extreme staff shortage, the nurse has been sent to the intensive care unit to assist registered nurses in the care of clients. The nurse understands that which factor is most important to consider when treating a client with cardiogenic shock?

-Restriction of volume expanders because of secondary pulmonary edema. (May have secondary issues such as pulmonary edema due to the ineffective pumping mechanism of the heart.)

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply.

-Temperature of 102° F (38.9° C) -Heart rate of 96 beats per minute -Mean arterial pressure 65 mm Hg

The nurse is caring for a client with a urinary tract infection diagnosed with sepsis. In reviewing the client's chart, the nurse notices that the C-reactive protein is elevated. The nurse plans care, knowing that the primary reason for this change is based on which interpretation?

-The body activates proinflammatory and anti-inflammatory responses. C reactive protein is inflammatory bio marker

Which finding indicates that tissue perfusion has been improved in a client with septic shock?

-The client's capillary refill is less than 3 seconds. (The primary goal of treatment and management of shock is to improve tissue perfusion.)

The nurse plans care understanding that which is the primary reason clients experience vasodilation in septic shock?

-There is a release of endotoxins from bacteria. (causes vasodilation, pooling of blood)

The nurse plans care for a client with sepsis, understanding that which of the following are characteristic of sepsis? Select all that apply.

1. The client can develop coagulopathy. (bleeding disorder, clots) 2. The infection can be caused by a parasite. 3. Sepsis is the bodily response to an infection. The client may display abnormal vital signs along with abnormal laboratory values.

Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits b. Urine output is 60 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal .d. Mean arterial pressure (MAP) is 65 mm Hg.

B. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful.

A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126,respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate? a. infusion of 5% human albumin. b. administration of furosemide (Lasix) IV. c. titration of an epinephrine (Adrenalin) drip d. administration of hydrocortisone (SoluCortef).

B. too much fluid need to get rid of it. The PAWP indicates that the patient's preload is elevated and furosemide is indicated toreduce the preload and improve cardiac output

When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusionto treat cardiogenic shock, which finding indicates that the medication is effective? a. No heart murmur is audible. b. Skin is warm, pink, and dry. c. Troponin level is decreased. d. Blood pressure is 90/40 mg

B.Warm, pink, and dry skin indicates that perfusion to tissues is improved.

The emergency department (ED) receives notification that a patient who has just been inan automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain? a. 500 mL of 5% albumin. b. lactated Ringer's solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion

C. MCV hypovolemic shock volume depleted and you need to transfuse VERY FAST. 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.

Which intervention will the nurse include in the plan of care for a patient who hascardiogenic shock? a. Avoid elevating head of bed. b. Check temperature every 2 hours. c. Monitor breath sounds frequently. d. Assess skin for flushing and itching.

C. Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently.

After receiving 1000 mL of normal saline, the central venous pressure (CVP) for a patient whohas septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nursewill anticipate the administration of? a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride). (vasodilator)

C. When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increasethe systemic vascular resistance (SVR) and improve tissue perfusion.

A patient with massive trauma and possible spinal cord injury is admitted to theemergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2° F (38.4° C)

C. signs of neurogentic shock are hypotension and bradycardia

To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patientwith systemic inflammatory response syndrome (SIRS), which assessment will the nurse make? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Monitor stools for occult blood. d. Check for abdominal distention.

C. ulsers bleed and can cause a GI bleed. Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients.

Which client would most likely be the highest risk for systemic inflammatory response syndrome (SIRS)?

-A client with cancer admitted for a central line placement. (The client with cancer is at increased risk for infection.)

A client who had a myocardial infarction is at risk for cardiogenic shock. The nurse plans care knowing that the primary cause of cardiogenic shock results from which process?

-A pump failure and reduction in cardiac output. Always pump failure

A client diagnosed with pneumonia has been hypotensive for the last four hours, with systolic blood pressures (SBP) ranging from 80 to 100 mm Hg. The nurse is concerned that the client may be developing sepsis. What intervention would the nurse anticipate taking priority for this client?

-Administer fluid resuscitation with isotonic crystalloids.

A client is admitted to a medical-surgical unit for observation following a motor vehicle crash (MVC). The client's liver function and pancreatic enzyme laboratory values are beginning to elevate. What initial actions would the nurse take in the care of the client? Select all that apply.

-Contact the primary health care provider (PHCP). -Prepare to treat a systemic inflammatory response. (Systemic inflammatory response syndrome (SIRS) is generalized inflammation in organs separate from the initial affected area. Can be caused by a severe infection (sepsis), trauma.)

A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the followingcollaborative interventions prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr .b. Keep head of bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg

A- already fluid overloaded with increased PAWP

A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulserate is 120 and the central venous pressure and pulmonary artery wedge pressure are low.Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c. Administer hydrocortisone (SoluCortef) 100 mg IV. d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.

A- already volume depleted

Norepinephrine (Levophed) has been prescribed for a patient who was admitted withdehydration and hypotension. Which patient information indicates that the nurse shouldconsult with the health care provider before administration of the norepinephrine? a. The patient's central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min d. The patient has had no urine output since being admitted.

A. Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock

A patient with cardiogenic shock is cool and clammy and hemodynamic monitoringindicates a high systemic vascular resistance (SVR). Which action will the nurseanticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion. b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.

D. Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output.