Hypovolemia ch.66

Ineffective tissue perfusion

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a. Acute pain b. Impaired tissue integrity c. Decreased cardiac output d. Ineffective tissue perfusion

a,c,d (Bowel obstruction causes relative hypovolemia by preventing fluid absorption for the bowel. A ruptured spleen may cause massive internal bleeding, leading to hypovolemia. Diabetes insipidus causes a marked increase in fluid loss through the kidneys, leading to hypovolemia.)

A nurse is assessing a patient who is suspected of having hypovolemic shock. What are the conditions that can cause hypovolemic shock? a. Ruptured spleen b. Valvular stenosis c. Bowel obstruction d. Diabetes insipidus e. Tension pneumothorax

a,b,c (Human serum albumin is used for increasing plasma colloid osmotic pressure and for rapid volume expansion. The patient should be monitored for circulatory overload. Because the patient is hypovolemic, a 5% solution of serum albumin should be used. Also, note that a 25% solution is used in patients with fluid and sodium restrictions. The infusion can cause mild side effects like chills, fever, and urticaria. Because the infusion is not reactive to light, protection from sunlight is not required, and it does not increase the risk of bleeding.)

A nurse is taking care of a patient with hypovolemic shock from a motor vehicle accident (MVA). The health care provider prescribes human serum albumin for fluid replacement. What should the nurse do to safely administer this medication? a. Monitor for circulatory overload. b. Use 5% solution of serum albumin. c. Monitor for chills, fever, and urticaria. d. Monitor for bleeding from potential sites. e. Prevent exposing the infusion to sunlight.

Begin crystalloid fluid replacement

A patient admitted to the hospital after a motor vehicle accident (MVA) is in hypovolemic shock. On examination, the nurse finds that the patient is becoming anxious, and the urine output is decreasing. What appropriate action should the nurse perform? a. Begin crystalloid fluid replacement. b. Start fluids only if deterioration occurs. c. Prepare for administering blood products. d. Wait for the patient to compensate naturally.

Monitor for the signs of circulatory overload

A patient in shock is receiving 0.9 % NaCl (normal saline solution-NSS). Which nursing intervention is appropriate for this patient? a. Monitor the patient's vital signs b. Monitor for the signs of circulatory overload c. Monitor for signs of hypernatremia in the patient d. Monitor for allergic reactions and acute renal failure

a,d (Colloidal solutions such as 5% human serum albumin may cause fluid and sodium retention, resulting in fluid overload. Therefore to prevent the risk of fluid overload in the patient, the nurse should check for signs of fluid overload, or hypervolemia. Colloidal solutions can cause chills, fever, and urticaria. Therefore the nurse should assess the patient for symptoms of urticaria in order to provide appropriate treatment. Unlike dextrose, human serum albumin does not increase the risk of bleeding in the patient. Human serum albumin causes sodium retention, so the nurse should check for the symptom of hypernatremia, not hyponatremia. Human serum albumin does not cause a decrease in plasma bicarbonate concentration and does not result in hyperchloremic acidosis.)

A patient is receiving 5% human serum albumin. The nurse should monitor for which complications associated with the infusion? a. Urticaria b. Bleeding c. Hyponatremia d. Fluid overload e. Hyperchloremic acidosis

inform the pt of the current plan of care and its rationale

A pt in shock has a nursing diagnosis of fear r/t severity of condition and perceived threat of death as manifested by verbalization of anxiety about condition and fear of death. What is an appropriate nursing intervention for the pt? a. administer antianxeity agents b. allow caregivers to visit as much as possible c. call a member of the clergy to visit the pt d. inform the pt of the current plan of care and its rationale

administer high-flow oxygen w/ a non-rebreather mask

A pt w/ acute pancreatitis is experiencing hypovolemic shock. which initial orders for the pt will the nurse implement first? a. start 1000 mL of NS at 500 ml/hr b. obtain blood cultures before starting IV antibiotics c. draw blood for hematology and coagulation factors d. administer high-flow oxygen w/ a non-rebreather mask

serum pH

A pt w/ hypovolemic shock is receiving LR solution for fluid replacement therapy. During this therapy, which laboratory result is the most important for the nurse to monitor? a. serum pH b. serum sodium c. serum potassium d. Hgb and Hct

Antidiuretic hormone (ADH) release increases water reabsorption

As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic change occurs r/t the increased angiotensin II? a. vasodilation b. decreased BP and CO c. aldosterone release results in sodium and water excretion d. Antidiuretic hormone (ADH) release increases water reabsorption

increased ammonia levels

In late irreversible shock in a pt w/ massive thermal burns, what should the nurse expect the pt's laboratory results to reveal? a. respiratory alkalosis b. decreased potassium c. increased BG d. increased ammonia levels

a, d, e

In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates the alpha-adrenergic stimulation? (SATA) a. skin b. brain c. heart d. kidneys e. gastrointestinal tract

decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells

Progressive tissue hypoxia leading to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contribute to this increasing tissue hypoxia? a. arterial constriction causes decreased perfusion b. vasoconstriction decreases blood flow to pulmonary capillaries c. increased capillary permeability and profound vasoconstriction cause increased hydrostatic pressure d. decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells

d,e (A 5% sodium chloride solution is a hypertonic solution that is used for initial volume expansion in patients with hypovolemic shock. The patient should be monitored for signs of hypernatremia, such as disorientation and convulsions. The infusion should be administered through a central line, because it can damage the peripheral veins. )

The health care provider prescribes 5% sodium chloride solution for the initial fluid replacement in a patient with hypovolemic shock. Which factors should the nurse consider when administering this solution to the patient? a. Monitor the patient for bleeding. b. Protect the infusion from sunlight. c. Monitor the patient for renal failure. d. Infuse the solution through a central line. e. Monitor the patient closely for signs of hypernatremia.

a,b,c,f

The nurse is caring for a patient who has hypovolemic shock from hemorrhage. The nurse expects to find which clinical manifestation(s)? a. Anxiety b. Tachycardia c. Hypotension d. Hypothermia e. Lactic acidosis f. Decreased capillary refill

Severe burns

The nurse is caring for a patient who has hypovolemic shock. Which medical diagnosis does the nurse suspect? a. Insect bite b. Severe burns c. Myocardial infarction d. Pulmonary embolism

Human serum albumin

The nurse is mentoring a graduate nurse and is explaining the use of fluids in a patient who is experiencing hypovolemic shock. Which of the following fluids increases osmotic pressure to provide rapid volume expansion? a. Lactated Ringer's b. 3% sodium chloride c. Fresh frozen plasma d. Human serum albumin

a,b,c

The nurse is reviewing orders for laboratory work for a patient who is experiencing shock. Which of the following tests would the nurse expect to be ordered? a. Creatinine b. Arterial blood gases c. Complete blood count d. Glycosated hemoglobin e. Prostate surface antigen

a, c, f

The pt is in compensatory stage of shock, what manifestations indicate this to the nurse? (SATA) a. pale and cool b. unresponsive c. lower BP than baseline d. moist crackles in the lungs e. hyperactive bowel sounds f. tachypnea and tachycardia

increased serum sodium

What abnormal finding should the nurse expect to find in early compensatory shock? a. metabolic acidosis b. increased serum sodium c. decreased BG d. increased serum potassum

inadequate tissue perfusion

What is the key factor in describing any type of shock? a. hypoxemia b. hypotension c. vascular collapse d. inadequate tissue perfusion

being aware of the potential for shock in all pts at risk

What is the priority nursing responsibility in the prevention of shock? a. frequently monitoring all pts vital signs b. using aseptic technique for all invasive procedures c. being aware of the potential for shock in all pts at risk d. teaching pts health promotion activities to prevent shock

a, b, e, f

What physical problems could precipitate hypovolemic shock? (SATA) a. burns b. ascites c. vaccines d. insect bites e. hemorrhage f. ruptured spleen

Replace clotting factors based on laboratory studies (When administering large volumes of packed RBCs, it is important to replace clotting factors to prevent coagulopathy. Because the pack contains only RBCs and not the clotting factors, it should be given extrinsically. Generally, the crystalloid and colloid solutions are warmed before being administered to avoid hypothermia. However, packed red blood cells should not be warmed, because high temperature can damage the red blood cells. The blood products are almost always cross typed and matched before administration. Antibiotics are not related to the administration of RBCs. )

When a patient suffers from hypovolemic shock due to loss of blood, the nurse should administer large volumes of packed red blood cells (RBCs). What should be the appropriate course of action for the nurse? a. Warm the pack before administering. b. Check the patient's hypersensitivity to the product. c. Provide antibiotics based on the clinical condition. d. Replace clotting factors based on laboratory studies.

a,c,d

When planning for home care of a patient who has just recovered from shock, what appropriate measures should the nurse follow? a. Admit to rehabilitation center. b. Allow the patient to resume work. c. Arrange for transitional care units. d. Refer to home health care agencies. e. Assure rapid recovery with self-care.

d,e (Isotonic fluids primarily remain in the intravascular space and increase the intravascular volume. Therefore the patient should be closely monitored for circulatory overload. Use of lactated Ringer's solution should be avoided in patients with liver failure, because it results in the accumulation of lactate.)

When using an isotonic fluid replacement for a patient who is in shock, what are important interventions that a nurse should perform? a. Monitor the patient for hypernatremia. b. Monitor the patient for hypersensitivity reactions. c. Administer the infusion only through a central line. d. Monitor the patient closely for circulatory overload. e. Avoid using lactated Ringer's solution in patients with liver failure.

a, b, c, e, f

Which indicators of tissue perfusion should be monitored in critically ill patients by the nurse? (SATA) a. skin b. urine output c. level of consciousness d. ADLs e. vital signs, including pulse oximetry f. peripheral pulses w/ cap refil

Hypovolemic shock

Which type of shock causes an absence of bowel sounds? a. Neurogenic shock b. Cardiogenic shock c. Hypovolemic shock d. Anaphylactic shock

a,b,d

While planning the management of oxygen delivery in a patient with shock, what appropriate measures should the nurse undertake? a. Administer supplemental oxygen as prescribed. b. Space activities that increase oxygen consumption. c. Space activities that decrease oxygen consumption. d. Monitor continuously by using a central venous catheter. e. Encourage the patient to move around to increase lung expansion.