Lewis Chapter 66 - Shock Questions

A patient presents to the emergency department (ED) in a state of shock. On assessment, the nurse finds that the patient is cyanotic and has crackles on auscultation of the lungs. As which type of shock will the nurse classify this?

Cardiogenic shock A patient with cardiogenic shock shows peripheral hypoperfusion presenting as cyanosis and has crackles on auscultation of the lungs due to pulmonary congestion. In neurogenic shock, the patient demonstrates symptoms related to the injury such as hypotension and bradycardia. The patient in hypovolemic shock may experience tachycardia as a late sign. In anaphylactic shock, the patient may experience wheezing and stridor.

A student nurse is caring for a patient diagnosed with sepsis. The student nurse tells the nurse the care plan regarding the administration of antibiotics. Which nursing action requires correction?

Delay antibiotics administration if the causative organism is unknown. More specific antibiotics may be ordered once the organism has been identified, but administration of antibiotics should not be delayed. Broad spectrum antibiotics are given first. Antibiotics are an important early component of therapy and should be started in the first hour. The nurse should obtain blood cultures before antibiotics are started.

The certified nursing assistant (CNA) reports that bright red blood has been found in the stool of a patient diagnosed with multiple organ dysfunction syndrome (MODS). The CNA asks the nurse about the cause of the blood in the stool. Which explanation by the nurse is most accurate?

"Decreased oxygen to the gastric mucosa leads to breakdown. Decreased perfusion leads to breakdown of the protective gastrointestinal (GI) mucosa, leading to GI bleeding, risk for ulceration, and bacterial movement from the GI tract into the circulation. The statement that acid production is increased due to the enteral feedings is an incorrect statement. Decreased gastric motility is common in critical illness and leads to paralytic ileus and abdominal distention, not GI bleeding. The medications used to treat MODS do not include GI bleeding as a side effect.

The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored? Select all that apply.

-Cardiac outputCardiac output -Available hemoglobin -Arterial oxygen saturation Oxygen delivery depends on cardiac output, available hemoglobin, and arterial oxygen saturation (SaO2). The amount of blood that the heart pumps to the body may decide the amount of oxygen delivered to the tissues. Hemoglobin, the protein content in red blood cells, is responsible for carrying oxygen molecules. Low hemoglobin means a low oxygen supply to the tissues. Arterial oxygen saturation indicates the total oxygen carried by the blood in the arteries and implies the level of tissue oxygenation. The urine output and white blood cells are also important parameters to be monitored in a patient who suffers from a shock. However, these do not impact the oxygen delivery directly.

A patient is admitted to the hospital with a suspected diagnosis of obstructive shock. What could be the possible causes of this type of shock? Select all that apply.

-Cardiac tamponade -Tension pneumothorax -Superior vena cava syndrome Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression caused by cardiac tamponade, tension pneumothorax, or superior vena cava syndrome. Hypersensitivity to antibiotics may cause anaphylactic shock. Spinal cord injury may lead to neurogenic shock.

A nurse is monitoring a patient for signs and symptoms related to septic shock. Which are late signs of this emergency condition? Select all that apply.

-Cool and mottled skin -Myocardial dysfunction Late signs of septic shock are cool and mottled skin and myocardial dysfunction. The release of platelet-activating factors increases coagulation, resulting in the formation of microthrombi and decreased blood flow in the microcirculation. The patient in early stages of septic shock may have warm and flushed skin, respiratory alkalosis, altered mental status, and decreased urine output. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A nurse is caring for a patient who is in a state of cardiogenic shock caused by myocardial infarction. The nurse uses pulse oximetry to monitor the oxygen saturation levels. Where should the nurse attach the pulse oximetry probe to get an accurate reading? Select all that apply.

-Ear -Nose -Forehead

In what order does the nurse recall the steps that cause a decrease in preload in patients with systemic inflammatory response syndrome (SIRS)?

-Endothelial damage due to the inflammatory state of the body -Increase in the capillary permeability -Shifting of albumin and fluid from the vascular space -Reduction of venous return -Decrease in the preload In patients with systemic inflammatory response syndrome (SIRS), there is an increase in capillary permeability caused by endothelial damage. Hence there is shifting of albumin and fluid from the vascular space. As a result, there is a reduction in venous return, which leads to a decrease in preload. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

What laboratory findings of a patient with systemic inflammatory response syndrome (SIRS) suggest progression to hepatic dysfunction? Select all that apply.

-Increase in serum ammonia -Decrease in serum transferrin Loss of liver function leads to the accumulation of waste products such as ammonia. Hence, an increase in the serum ammonia level indicates hepatic dysfunction. In patients with SIRS, the plasma transferrin level helps to assess protein synthesis. When hepatic dysfunction occurs, there is a decrease in serum transferrin. In hepatic dysfunction, there is accumulation of bilirubin. A bilirubin level greater than 34 µmol/L suggests hepatic dysfunction. A urine NA+ level of 24 mEq/L indicates acute tubular necrosis or an intrarenal manifestation of renal system dysfunction. It does not indicate hepatic dysfunction. Ventilation-perfusion (V/Q) mismatch suggests development of acute respiratory distress syndrome (ARDS) rather than hepatic dysfunction.

State the order in which the nurse recalls that the steps of how the systemic inflammatory response syndrome (SIRS) leading to an increase in cardiac output occurs.

-Increase in tissue O2 demands -Massive dilation of blood vessels -Decrease in blood pressure and systemic venous return -Activation of baroreceptor reflex -Release of inotropic and chronotropic factors Systemic inflammatory response syndrome (SIRS) increases tissue oxygen demands, which causes myocardial depression and massive vasodilation. The vasodilation results in a decrease in blood pressure and systemic venous return, which activates the baroreceptor reflex, causing release of inotropic and chronotropic factors. The inotropic factors increase the force of contraction while the chronotropic factors increase the heart rate. The result is an increase in cardiac output. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

The nurse has obtained the liver function test report of a patient with multiple organ dysfunction syndrome. What hepatic parameters is the nurse likely to find in the laboratory report? Select all that apply.

-Increased liver enzymes -Increased ammonia (NH3) -Increased bilirubin greater than 2 mg/dL The patient with multiple organ dysfunction has compromised hepatic function manifested by increased ammonia, bilirubin levels greater than 2 mg/dL, and increased liver enzymes. Hepatic hypoperfusion and the resultant cell damage may result in decreased serum albumin and transferrin. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

When examining a patient in the progressive stage of shock, which factors related to the gastrointestinal (GI) system should the nurse consider? Select all that apply.

-Increased risk of GI bleeding -Increased likelihood of GI ulcers -Increased risk of bacterial migration from the GI tract to the bloodstream. In the progressive stage of shock, the GI system gets affected by prolonged decreased tissue perfusion. As the blood supply to the GI tract is decreased, the normally protective mucosal barrier becomes ischemic. This ischemia predisposes the patient to ulcers and GI bleeding. It also increases the risk of bacterial migration from the GI tract to the blood. The decreased perfusion to the GI tract also results in a decreased ability to absorb nutrients, decreased motility, and slowed peristalsis.

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? Select all that apply.

-Infuse the solution through a central line. -Monitor the patient closely for signs of hypernatremia. 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 solution does not increase the risk of bleeding and is not photosensitive. Also, it does not increase the risk of renal failure. Test-Taking Tip: Survey the test before you start answering the questions. Plan how to complete the exam in the time allowed. Read the directions carefully and answer the questions you know for sure first.

Which types of shock are associated with decreased cerebral perfusion? Select all that apply.

-Obstructive shock -Cardiogenic shock -Hypovolemic shock Manifestations of cardiogenic shock include decreased cerebral perfusion causing anxiety, confusion and agitation. Decreased cerebral perfusion associated with obstructive shock causes anxiety, confusion, and agitation. Decreased cerebral perfusion associated with hypovolemic shock causes anxiety, confusion and agitation. Septic shock causes mental changes like confusion, agitation, and coma in the late stages. Loss of reflex activity and flaccid paralysis are seen with neurogenic shock. Anxiety, metallic taste, confusion, and impending doom are signs of hypovolemic shock. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

The nurse is evaluating lab results related to the hematologic system for a patient diagnosed with multiple organ dysfunction syndrome (MODS) following a traumatic injury. Which lab results indicate involvement of the hematologic system? Select all that apply.

-PT 18 sec -D-Dimer 280 ng/mL -Platelets 125 x 103/μL Increased PT, increased D-dimer, and decreased platelets indicate involvement of the hematologic system. Normal PT is 11-16 sec; normal platelets are 150-400 x 103/ μL, and normal D-dimer is less than 250 ng/mL. These all indicate involvement of the hematologic system. Normal Hct is 39%-50% for males and 35%-47% for females, thus this result is within normal range. RBC values range from 3.8/4.3-5.1/5.7 x 106/μL (male/female) thus this result is within normal limits.

When examining a patient with septic shock, what symptoms would the nurse expect to find? Select all that apply.

-Paralytic ileus -Decreased urinary output -Gastrointestinal (GI) bleeding Patients suffering from septic shock may experience decreased tissue perfusion, which may result in a paralytic ileus, GI bleeding, and decreased urinary output. Pulsus paradoxus and jugular vein distension are found in obstructive shock and are mainly the result of compromised hemodynamics.

A nurse is caring for a 52-year-old patient receiving chemotherapy for lung cancer. Which strategies should the nurse take to reduce the risk for opportunistic infections thereby reducing the risk of sepsis? Select all that apply.

-Pay strict attention to thorough handwashing -Use aseptic technique during invasive procedures -Thoroughly clean or discard equipment between patients Patients who are immunocompromised are at a high risk for opportunistic infection. Strategies to decrease the risk of infection include paying attention to strict handwashing, using aseptic technique during invasive procedures, and thoroughly cleaning or discarding equipment between patients. Changing the IV site daily increases the risk of infection. Antibiotics are not administered prophylactically.

A patient in cardiogenic shock is prescribed a dose of sodium nitroprusside. What appropriate actions should the nurse perform to safely administer sodium nitroprusside? Select all that apply.

-Protect solution from light -Wrap infusion bottle with opaque covering -Monitor the serum cyanide levels and signs of cyanide toxicity. Sodium nitroprusside is a vasodilator used in cardiogenic shock. The drug tends to release cyanide ions when exposed to sunlight. Therefore it should be protected from exposure to sunlight by wrapping the infusion bottle with an opaque covering. The patient's serum cyanide levels should be checked, and the patient should be monitored for signs of cyanide toxicity. This includes metabolic acidosis, tachycardia, altered level of consciousness, seizures, coma, and almond smell on the breath. The medication should be reconstituted with D5W only. Monitoring vital signs like body temperature is important but may not directly impact the treatment being administered.

A nurse is examining a patient with anaphylactic shock due to an insect bite. What types of skin manifestations would the nurse expect to find? Select all that apply.

-Pruritus -Flushing -Urticaria Insect bites may cause allergic reactions and anaphylactic shock. The skin manifestations may include pruritus, flushing, and urticaria caused by massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. Pallor and cold, clammy skin changes are usually seen in cardiogenic, hypovolemic, and obstructive shock caused by decreased circulatory volume and tissue perfusion.

Which findings indicate the development of acute respiratory distress syndrome (ARDS) in a patient with systemic inflammatory response syndrome (SIRS)? Select all that apply.

-Pulmonary hypertension -Decreased lung compliance -Bilateral diffuse infiltrates in the chest In patients with SIRS, the inflammatory mediators leading to pulmonary hypertension directly affect the pulmonary vasculature. The patient with acute respiratory distress syndrome shows decreased compliance due to the combined effects of pulmonary vasoconstriction and bronchoconstriction. There are bilateral diffuse fluffy infiltrates seen on the chest x-ray. The minute ventilation increases as the patient experiences tachypnea.

A diabetic patient being cared for following amputation of the left lower leg has large amounts of purulent drainage from the stump and redness and edema around the stump wound. The patient is lethargic and confused. Vital signs include a blood pressure of 80/60 mm Hg, respiratory rate of 32 breaths/minute, and pulse of 112 beats/minute. Which signs and symptoms would support a diagnosis of multiple organ dysfunction syndrome (MODS)? Select all that apply.

-Pulse of 112 beats/minute -Lethargy and confusion -Respiratory rate of 32 breathes/minute -Blood pressure of 80/60 mm Hg Lethargy and confusion indicate neurologic dysfunction, while tachycardia, tachypnea, and hypotension characterize respiratory and cardiac manifestations of MODS. Stump drainage and wound redness and edema characterize signs of an infection, which could be related to the development of MODS but are not diagnostic of MODS.

In what order does the nurse recall the steps of how systemic inflammatory response syndrome (SIRS) causes acute kidney injury?

-Redistribution or shunting of blood flow due to the inflammatory state of the body -Decreased perfusion of the kidney -Activation of the sympathetic nervous system (SNS) and the renin-angiotensin system -Systemic vasoconstriction and sodium and water reabsorption -Development of acute kidney injury Systemic inflammatory response syndrome (SIRS) causes redistribution or shunting of blood flow, leading to decreased perfusion of the kidney, which activates the sympathetic nervous system (SNS) and stimulates the renin-angiotensin system. Stimulation of the renin-angiotensin system leads to systemic vasoconstriction. It also causes aldosterone-mediated sodium and water reabsorption, leading to acute kidney injury. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

Vasopressor agents are prescribed for which types of shock? Select all that apply.

-Septic shock -Neurogenic shock Septic shock occurs in response to an infection. It is associated with the release of cytokines and other inflammatory mediators, resulting in vasodilatation, increased capillary permeability, and platelet aggregation. Vasopressors will constrict the blood vessels and relieve hypotension. Neurogenic shock is caused by a severe injury to the CNS causing a loss of sympathetic stimulation of blood vessels resulting in vasodilatation. A fall in blood pressure can be restored by administering vasopressor agents that act by constricting the blood vessels. Obstructive shock is caused by an obstruction in the vessels of the heart or the heart itself. Restoring the circulation by treating the cause of obstruction will be beneficial for a patient with obstructive shock. Systolic or diastolic dysfunction of the heart results in cardiogenic shock. Treatment involves use of nitrates, inotropes, diuretics, and beta-blockers. A loss in the intravascular fluid volume causes hypovolemic shock. Treatment of hypovolemic shock includes restoring the fluid volume by infusion of blood or blood products and crystalloids. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

When managing a patient with shock, which appropriate actions should the nurse take as part of nutritional therapy? Select all that apply.

-Start enteral nutrition within the first 24 hours -Start parenteral nutrition if enteral feedings are contraindicated -Start a slow continuous drip of small amounts of enteral feedings. Enteral nutrition should ideally begin within the first 24 hours. It is important because it enhances the perfusion of the (gastrointestinal) GI tract and helps to maintain the integrity of the gastrointestinal mucosa. Enteral feeding should be started with a slow continuous drip of small amounts of enteral feedings. If enteral feedings are contraindicated, parenteral feedings can be started. Enteral feeding should be planned to meet at least 80 percent of the total calorie requirements, but if it is not feasible, parenteral feeding should be started. Nutritional therapy should start as early as possible. The nurse should not wait for the patient to recover before starting nutritional therapy.

Which are pathophysiologic effects of septic shock? Select all that apply.

-Vasodilation -Myocardial depression -Maldistribution of blood flow Septic shock has three major pathophysiologic effects: vasodilation, myocardial depression, and maldistribution of blood flow. The release of platelet-activating factors increases coagulation rather than decreasing it, resulting in the formation of microthrombi and decreased blood flow in the microcirculation. Sepsis-induced myocardial dysfunction results in a decreased, not increased, ejection fraction. Because coagulation is increased, blood flow in the microcirculation is decreased, not increased.

A nurse is caring for a patient diagnosed with septic shock. The patient weighs 75 kg. The healthcare practitioner orders intravenous (IV) fluid resuscitation of 30 mL/kg. How many milliliters will the nurse infuse? Record your answer using a whole number and no punctuation. _________ mL

70 kg x 30 mL/kg = 2250 mL. The nurse should infuse 2250 mL of IV fluid as ordered.

A patient is brought to the emergency department (ED) after multiple bee stings. On assessment, the nurse finds that the patient has edema on the lips and tongue as well as chest pain, dizziness, wheezing, and stridor. What type of shock should the nurse document this as?

Anaphylactic shock Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is insect venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above. Obstructive shock develops when a physical obstruction to blood flow occurs with decreased cardiac output.

Which type of shock is associated with hyperglycemia, presence of pulmonary infiltrates in chest x-ray and increased levels of blood urea nitrogen (BUN)?

Cardiogenic Increased blood levels of glucose, nitrogen, and cardiac markers and presence of pulmonary infiltrates are seen in cardiogenic shock. Increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of which condition?

Cardiogenic shock One of the initial cardinal signs of cardiogenic shock after a myocardial infarction (MI) is a slow, steady drop in blood pressure. Hypotension after an MI may be an indirect sign of a secondary MI or a fatal dysrhythmia. Depending on the origin of pulmonary edema, patients may experience hypotension or hypertension.

A nurse is assessing a patient admitted with septic shock. The nurse notes the patient is anxious, confused, and agitated. The nurse knows that these symptoms are signs of impairment of which process?

Cerebral perfusion Patients in septic shock who have impaired cerebral perfusion may develop anxiety, confusion, and agitation. Decreased kidney perfusion results in sodium and water retention and decreased urine output. Signs of respiratory failure include tachypnea, crackles, and cyanosis. Signs of cardiovascular dysfunction include tachycardia and hypotension.

What is the best intervention for a patient with multiple organ dysfunction syndrome (MODS), renal failure, and signs of hemodynamic instability?

Continuous renal replacement therapy Continuous renal replacement therapy is considered the best intervention for the patient. In patients with renal failure and hemodynamic instability, continuous renal replacement therapy is better tolerated than hemodialysis. Diuretic therapy may be given in patients with prerenal manifestations due to MODS. However, diuretics are not administered in renal failure, because they are nephrotoxic and can worsen the acute tubular necrosis, leading to acute kidney injury. Aggressive oxygen therapy is not an intervention for renal failure. It is given to MODS patients with acute respiratory distress syndrome.

What causes gut bacteria to move into circulation in patients with systemic inflammatory response syndrome (SIRS)?

Decreased perfusion of gut mucosa Decreased perfusion in the gastrointestinal (GI) tract leads to a breakdown of the normally protective mucosal barrier, which causes the bacterial movement from the GI tract into circulation. In order to control these bacteria, antibiotics are administered. Antibiotics are nephrotoxic medicines that can cause acute kidney injury. The breakdown of the mucosal barrier is the direct effect of hypoperfusion rather than the inflammatory mediators. In critical illnesses, GI motility is often decreased causing abdominal distension and paralytic ileus. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)?

Decreased respiratory compliance Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism. Serum albumin is not increased, GI motility decreases in MODS, and the BUN/Creatinine ratio likely will increase.

A patient who suffered a massive myocardial infarction two weeks ago developed multiple organ dysfunction syndrome three days ago. Despite mechanical ventilation, sedation, and nutritional and cardiac support, the patient has not responded. The primary care provider has indicated that further interventions will likely be unsuccessful. Which option does the nurse anticipate being discussed next with the patient's family?

Discussion of life support withdrawal and initiation of end-of-life care If a patient is not responding to treatment efforts, the healthcare team and the patient's family will need to discuss realistic goals and options, such as withdrawal of life support and end-of-life care. Transfer to a different facility will not change the probable outcome. A patient who has not responded to treatment for MODS would not be helped by additional consults. Determining whether or not the patient meets the legal criteria for brain death may occur but would not be the next option.

Septic shock is classified as which type of shock?

Distributive Septic shock is classified as distributive shock, which is a result of abnormal distribution of blood flow causing an inadequate supply of blood to meet the metabolic needs of the body's tissue and organs. Septic shock is characterized by hypotension and inadequate tissue perfusion resulting in inadequate supply of blood to meet the metabolic needs of the body's tissues and organs. Neurogenic shock, anaphylactic shock, and septic shock are all classified as distributive shock. Cardiogenic shock occurs when there is either systolic or diastolic dysfunction of the heart's pumping action, resulting in reduced cardiac output. Obstructive shock develops when a physical obstruction to blood flow occurs with a decrease in cardiac output. Hypovolemic shock occurs after a loss of intravascular fluid volume.

The release of platelet-activating factors in patients who have sepsis triggers which response?

Formation of microthrombi The release of platelet-activating factors in patients with sepsis triggers the formation of microthrombi, causing obstruction of the microvasculature. Third spacing involves fluid moving out of the vascular space into the extravascular space as a result of hypovolemia. The release of vasoactive mediators in anaphylactic shock causes increased capillary permeability; this does not occur with sepsis. In sepsis, the production of cytokines is increased.

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?

Human serum albumin Human serum albumin is a colloidal fluid that increases osmotic pressure and will provide rapid volume expansion. Lactated Ringer's and 3% sodium chloride are used for initial volume replacement in shock, but they do not provide rapid volume expansion. Fresh frozen plasma is used to replace blood loss and replace coagulation factors.

The nurse would recognize which clinical manifestation as suggestive of sepsis?

Hyperglycemia in the absence of diabetes Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis, along with tachypnea and tachycardia, not bradypnea and bradycardia. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of this text over an extended period of time ensures your understanding of the mechanics of the examination and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success.

Which type of shock causes an absence of bowel sounds?

Hypovolemic shock Absence of bowel sounds is associated with hypovolemic shock. Decreased bowel sounds are seen with cardiogenic shock. Bowel dysfunction is associated with neurogenic shock. Abdominal pain, nausea, and vomiting are seen with anaphylactic shock. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options .

What laboratory finding correlates with a medical diagnosis of cardiogenic shock?

Increased blood urea nitrogen (BUN) and serum creatinine levels The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, whereas white blood cell levels typically do not increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia. Test-Taking Tip: Bring to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).

A patient in septic shock is receiving fluid resuscitation. How will the nurse most accurately measure urine output?

Indwelling urinary catheter The nurse will insert an indwelling urinary catheter to measure adequate urine output. Strict input and output and daily weights are not exact enough for measuring urine output. A nasogastric tube is not related to measuring urine output.

A patient diagnosed with sepsis fails to respond to fluid resuscitation. The healthcare provider orders the patient to be started on a vasopressor. The nurse evaluates which response to determine the effectiveness of the vasopressor?

Mean arterial pressure greater than 65 mm Hg The goal of vasopressor therapy is to maintain a mean arterial pressure greater than 65 mm Hg. Fluids can be increased or vasopressor therapy can be decreased if the patient develops hypotension. Vasopressors do not have an effect on lactic acid results or SpO2. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

What therapy is provided to a patient with acute respiratory distress syndrome (ARDS)?

Mechanical ventilation A patient with acute respiratory distress syndrome (ARDS) would be intubated and receive mechanical ventilation. Small volume nebulizer treatments would open airways; however, this intervention will not sufficiently treat ARDS. Oxygen via a Venturi mask or a non-rebreather mask would be insufficient to promote oxygenation and perfusion.

A patient in shock is receiving 0.9 % NaCl (normal saline solution-NSS). Which nursing intervention is appropriate for this patient?

Monitor for the signs of circulatory overload Circulatory overload occurs due to fluid overload. Continuous infusion of 0.9% NaCl increases the fluid volume in the body and may cause circulatory overload. The patient's vital signs must be checked during transfusion of blood or blood products because they could cause an infection or an allergic reaction. Hypernatremia occurs when the patient is on 1.8%, 3%, and 5% NaCl infusions. Infusion of dextran-40 has a tendency to precipitate allergic reactions and acute renal failure. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

Which type of shock is associated with bradycardia?

Neurogenic shock Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. Reduction in preload, capillary refill, and stroke volume are clinical manifestations of hypovolemic shock. Chest pain is seen in anaphylactic shock. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

When choosing a vasopressor for a septic patient who is not responsive to fluid resuscitation, which drug would the nurse expect the healthcare provider to most likely order?

Norepinephrine Norepinephrine is the drug of choice when a patient is no longer responsive to fluid. Dopamine is used in patients who are unable to achieve and maintain cardiac output. Vasopressin may be added for patients who are refractory to initial vasopressor therapy. Hydrocortisone may be considered in patients in septic shock who cannot maintain adequate blood pressure with vasopressor therapy despite fluid resuscitation.

What is the goal in the care of a systemic inflammatory response syndrome (SIRS) patient whose bilirubin level is 3 mg/dL?

Patient will maintain adequate tissue perfusion. The nurse will plan to maintain adequate tissue perfusion for a systemic inflammatory response syndrome (SIRS) patient with bilirubin level of 3 mg/dL. An elevation of the bilirubin indicates impaired liver function. Stress ulcer prophylaxis is routine and would have been initiated before SIRS occurred. Abdominal distention and increased intraabdominal pressures are associated with impaired liver function. Monitoring these conditions is essential but is of a lower priority than maintaining tissue perfusion.

A nurse is developing a care plan for optimum nutrition for a patient with multiple organ dysfunction syndrome (MODS) caused by sepsis. Which nutritional combination is most appropriate for this patient?

Protein and calories Protein and calorie malnutrition is one of the primary signs of hypermetabolism in MODS. The goal of nutritional support is to preserve organ function by providing early and optimal nutrition. Minerals and carbohydrates may be incorporated into the patient's nutrition plan but are not as helpful as protein and calories.

What is the clinical manifestation of systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) on the respiratory system?

Pulmonary hypertension Systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) affect the respiratory system and lead to pulmonary hypertension. Pulmonary edema is caused by fluid accumulation in the air spaces. Pulmonary fibrosis is a respiratory disorder caused by scars in the lung tissues or inhalation of airborne toxins. A pulmonary embolism is caused by blood clots or blockage in the pulmonary arteries.

A nurse is caring for a patient diagnosed with septic shock. The patient develops dyspnea, tachycardia, and bilateral lung crackles. The nurse suspects the patient has developed acute respiratory distress syndrome (ARDS). Which intervention is the nurse's priority?

Pulmonary management with mechanical ventilation Patients with ARDS need aggressive pulmonary management with mechanical ventilation. Repeat chest radiograph may be done after initiation of mechanical ventilation. Arterial blood gas measures respiratory alkalosis in early stages of septic shock and metabolic acidosis in late stages of septic shock. Broad spectrum antibiotics are important in the early component of therapy and should be started within the first hour of severe sepsis or septic shock, but once breathing is compromised, that becomes the priority. Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care.

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?

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. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. NCLEX item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

The nurse reviews the medical record of a patient with pneumonia and notes that the patient has hypotension, hypothermia, leukocytosis, and hypoxemia. What should the nurse infer from these findings?

The patient has septic shock Septic shock is most commonly found in the patient having gram-negative bacterial infections, such as pneumonia. Because it is characterized by hypotension, hypothermia, leukocytosis, and hypoxemia in patients with infections, the nurse concludes that the patient has septic shock. Neurogenic shock is most commonly seen in the patient who has an injury. Cardiogenic shock is caused by cardiovascular disorders, such as a myocardial infarction and cardiomyopathy. Hypovolemic shock is caused by hemorrhage or trauma. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

A patient diagnosed with multiple organ dysfunction syndrome is developing pulmonary edema. The nurse realizes that which factor is the cause of the edema?

Uncontrolled systemic inflammation During sepsis, early activation of immune cells is followed by down-regulation of their activity, which leads to a state of immune deficiency and increased risk of superinfection. Proinflammatory mediators increase capillary permeability, resulting in edema in organs such as the lungs. This is why the patient is developing pulmonary edema. Evidence of tissue hypoxia will occur in the gastrointestinal tract and the brain first. Unregulated apoptosis is uncontrollable cellular death. Pulmonary edema is not a symptom of unregulated apoptosis. Microvascular coagulopathy will manifest as abnormal clotting factors and microembolism production. Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.

What finding in the laboratory reports of a patient with multiple organ dysfunction syndrome (MODS) suggests to the nurse that the patient has acute tubular necrosis?

Urine Na + is 22 mEq/L A urine Na+ greater than 20 mEq/L is suggestive of acute tubular necrosis. A bilirubin level higher than 2 mEq/L suggests hepatic dysfunction rather than renal dysfunction. Urine specific gravity above 1.020 and a BUN/creatinine ratio higher than 20:1 indicate renal hypoperfusion rather than acute tubular necrosis.

Systemic inflammatory response syndrome (SIRS) in a patient seems to have progressed to dysfunction of the renal system. How are the manifestations of acute tubular necrosis different from those of renal hypoperfusion?

Urine specific gravity is around 1.010 in acute tubular necrosis and greater than 1.020 in renal hypoperfusion. In patients with acute tubular necrosis, the urine specific gravity is around 1.010, whereas it is greater than 1.020 in patients with renal hypoperfusion. Urine Na+ is greater than 20 mEq/L in patients with acute tubular necrosis and greater than 20 mEq/L in patients with renal hypoperfusion. Urine osmolality is decreased in cases of acute tubular necrosis, whereas it is increased in cases of renal hypoperfusion. Blood urea nitrogen/creatinine ratio is less than 10:1 to 15:1 in cases of acute tubular necrosis and greater than 20:1 in cases of renal hypoperfusion.

Which findings in a patient with systemic inflammatory response syndrome (SIRS) help the nurse identify cardiovascular system dysfunction? Select all that apply.

-Decrease in blood pressure -Decrease in mean arterial pressure -Decrease in systemic vascular resistance A patient with SIRS may have cardiovascular system dysfunction manifested as a decrease in blood pressure, mean arterial pressure, and systemic vascular resistance. Heart rate, stroke volume, and cardiac output tend to increase in such patients.

The nurse is taking care of a patient with cardiogenic shock due to a myocardial infarction. The health care provider prescribes dopamine to be administered. What nursing intervention should the nurse perform for administering dopamine? Select all that apply.

-Administer via a central line -Monitor for tachydysrhythmias -Monitor for peripheral vasoconstriction Dopamine is a positive inotropic agent used in cardiogenic shock. The drug may cause tissue sloughing, if infiltrated. Therefore it is administered through a central line and not via a peripheral line. The patient should be monitored for tachydysrhythmias caused by enhanced inotropic effects. There is also a risk of peripheral vasoconstriction, so the nurse should be observant for symptoms such as paresthesia and coldness of the extremities. The drug may get deactivated by an alkaline solution; therefore it should not be administered along with sodium bicarbonate. Because dopamine is not known to have an adrenergic action, it will not cause dyspnea and pulmonary edema.

A patient has been brought to the emergency department (ED) in a semiconscious state. The history collected from family members indicates that the patient consumed shellfish after which he experienced itching, difficulty breathing, and confusion. What treatment should the nurse anticipate for this patient? Select all that apply.

-Famotidine -Epinephrine -Diphenhydramine Epinephrine is the drug of choice to treat anaphylactic shock. It causes peripheral vasoconstriction and bronchodilation and opposes the effect of histamine. Famotidine is administered to prevent gastrointestinal ulcers and bleeding. IV diphenhydramine is given to block the excessive release of histamine due to an allergic reaction. Dobutamine is given in cases of cardiogenic shock. Low-molecular-weight heparin is usually given in cases of septic shock as a prophylaxis against venous thromboembolism.

A patient diagnosed with septic shock receives aggressive fluid resuscitation. In order to have the patient perform a passive leg raise, in what order should the nurse perform the following actions?

-Lay the patient supine. -Raise the legs to 45 degrees -Measure cardiac output -Evaluate the patient for hemodynamic improvement When performing a passive leg raise, the patient is placed supine, and the nurse then raises the patient's legs to 45 degrees. The nurse measures responsiveness in one to two minutes by measuring cardiac output. The nurse then evaluates the patient for hemodynamic improvement.

A patient being cared for in the critical care unit for pancreatitis and subsequent development of multiple organ dysfunction syndrome (MODS) is exhibiting gastrointestinal symptoms including bleeding. Which prescriptions does the nurse anticipate the healthcare provider will order to address the gastrointestinal issues? Select all that apply.

-Maalox -Sucralfate -Omeprazole Antacids like Maalox, proton pump inhibitors like omeprazole, and sucralfate are all indicated to treat issues related to injury to the gastric mucosa in MODS. Atorvastatin is a cholesterol-lowering agent and thus not indicated in this situation. Loperamide is an antidiarrheal and not appropriate based upon the information provided.

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? Select all that apply.

-Monitor for circulatory overload. -Use 5% solution of serum albumin -Monitor for chills, fever, and urticaria 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.

Which should the nurse evaluate when performing an assessment of end organ function on a patient who received fluid volume resuscitation for septic shock? Select all that apply.

-Urine output -Peripheral pulses -Neurologic function The goal for fluid resuscitation is restoration of tissue and end organ perfusion. An assessment of end organ perfusion includes urine output, peripheral pulses, and neurologic function. Visual acuity, oral mucosa, and bowel sounds do not provide relevant data for the nurse to evaluate end organ function.

What causes acute kidney injury (AKI) in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply.

-Use of nephrotoxic drugs -Effects of inflammatory mediators -Decreased perfusion to the kidneys Antibiotics commonly used to treat gram-negative bacteria are often nephrotoxic. These nephrotoxic drugs are one of the causes of acute kidney injury (AKI). Inflammatory mediators and hypoperfusion are causes of AKI. Decreased urine output and aldosterone-mediated sodium and water reabsorption are manifestations rather than causes of AKI. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Patients in septic shock require large amounts of fluid replacement. The nurse would expect the healthcare practitioner to order an amount of fluids in which range to achieve adequate fluid resuscitation?

30-50 mL/kg Patients in septic shock require volume resuscitation of 30-50 mL/kg with isotonic crystalloids to achieve adequate fluid resuscitation. A volume of 20-40 mL/kg is too little. A volume of 40-50 mL/kg does not express the full expected range. A volume of 60 mL/kg is too high an upper limit. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

A nurse is caring for a patient diagnosed with septic shock. After an infusion of 30 mL/kg of intravenous fluids, the patient is assessed and has a temperature of 101.4°F (38.6°C), a heart rate of 92 beats/minute, respiration rate of 20 breaths/minute, and a blood pressure of 80/60 mm Hg. Which nursing intervention is a priority for this patient?

Administer a vasopressor Patients in septic shock with persistent hypotension who do not respond to fluid resuscitation should be placed on a vasopressor. The physiologic goal is to increase cardiac output and end organ perfusion. The nurse should redraw the lactic acid, obtain a 12-lead ECG, and insert an indwelling urinary catheter while caring for this patient, but these can take place following administration of a vasopressor.

A nurse is caring for a 60-year-old patient with sepsis stemming from cellulitis to the right lower extremity. The patient's core temperature is 101.6° F (38.8° C). Which strategy to reduce the patient's temperature should the nurse implement?

Administer antipyretics. The nurse should treat the patient's fever with antipyretics and remove the patient's covers or use light sheets. Bathing the patient with warm water will not assist in lowering the patient's core body temperature, and the nurse should decrease the room temperature.

A nurse is reviewing the chart of a 68-year-old patient admitted with pneumonia. The nurse knows that the patient has the potential to develop sepsis based on which risk factors?

Age Sepsis is a constellation of symptoms or syndrome in response to an infection. Advanced age, recent surgery, a history of chronic disease, and immunosuppressive therapy like chemotherapy puts a patient at a greater risk for infection. Hearing loss and daily intake of multivitamins do not increase a patient's risk of infection.

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient?

Aggressive IV crystalloid fluid resuscitation Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock.

A nurse is caring for multiple patients. Which patient does the nurse monitor most closely for possible development of sepsis?

An 86-year-old patient with a fever and history of chronic urinary tract infections Advanced age, recent surgery, history of chronic disease, and immunosuppressive therapy put a patient at risk of infection. Due to these factors, the 86-year-old patient with a fever and chronic infections has the highest risk for developing sepsis. The 62-year-old patient has risk factors of advanced age and chronic disease, but the lack of fever puts this patient at a lower risk. The 7-year-old patient only exhibits one risk factor, and the 54-year-old patient does not exhibit any risk factors.

Which form of shock is associated with pruritus?

Anaphylactic shock Pruritus is a clinical manifestation of anaphylactic shock. Septic shock is initially associated with warm and flushed skin with later changes that include cool and mottled skin. Warm or cool and dry skin is a sign of neurogenic shock. Pale, cool, and clammy skin is a sign of obstructive shock. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.

Which type of organism most commonly causes sepsis?

Bacteria The most common organisms that cause sepsis are gram-negative and gram-positive bacteria. Fungi, viruses, and parasites can also cause sepsis but not as frequently.

Which cardiovascular change is commonly found in patients with systemic inflammatory response syndrome (SIRS)?

Decrease in capillary refill Patients with systemic inflammatory response syndrome (SIRS) have decreased capillary refill. Other cardiovascular changes include increases rather than decreases in heart rate, central venous pressure, and pulmonary artery wedge pressure. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

A nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) caused by sepsis. Which is the most appropriate communication with the caregiver when further treatment is futile?

Discuss realistic goals and likely outcomes When further treatment is futile, the nurse should have a conversation with the patient's caregiver about realistic goals and likely outcomes for a patient with MODS. The nurse should not give the caregiver false hope. Discussing options is appropriate communication with the caregiver, but encouraging the caregiver to withdraw life support does not empower the caregiver's autonomy. Asking the caregiver if he or she want to see the clergy is not the most appropriate response at this time. This is more appropriate to offer after discussion of goals and likely outcomes.

A patient is showing signs of anaphylactic shock from an insect sting. Which primary health care provider's prescription does the nurse implement first?

Epinephrine 1:1000, 0.5 mg subcutaneous (SQ) The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. Although administering normal saline, diphenhydramine, and oxygen are appropriate, they must be done after an airway has been established.

If the patient in shock is to receive 1000 mL of normal saline in two hours, at what rate should the infusion pump be set? Record your answer using a whole number. ___mL/hour

For the 1000 mL of normal saline to be infused in two hours, the infusion pump should be set at 500 mL per hour (1000 mL divided by two hours). Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.

When reciting to the nursing instructor mechanisms that can trigger the systemic inflammatory response syndrome (SIRS) associated with sepsis, which listed by the student nurse requires correction?

Hypertension Hypertension is not a mechanism that triggers SIRS. SIRS is a response to a variety of mechanisms, including burns, abscess, and pancreatitis.

A nurse is evaluating a patient admitted with sepsis who received large amounts of fluid resuscitation in the emergency room. Which is the priority for the nurse to evaluate concerning possible complications caused by large fluid volume administration?

Hypothermia and coagulopathy When large amounts of fluid are required, the nurse must assess the patient for two major complications: hypothermia and coagulopathy. Hypokalemia and hyperglycemia must be assessed when patients receive hydrocortisone. Reflex bradycardia and headache are side effects of phenylephrine. Cardiac stimulation and bronchodilation are intentionally induced with the use of epinephrine in anaphylactic shock. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A nurse is caring for a patient in the intensive care unit (ICU) admitted with septic shock. The patient has been in the ICU for 36 hours. After 24 hours, which finding increases the patient's risk for developing multiple organ dysfunction syndrome (MODS)?

Increased cardiac output If increased cardiac output persists after 24 hours, the patient in septic shock is at risk of developing hypotension and MODS. Coronary artery perfusion is not primarily altered in septic shock. Decreased, not increased, systemic vascular resistance is associated with an increased risk of MODS. Septic shock does not typically alter myocardial oxygen metabolism.

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis?

Ineffective tissue perfusion The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output, because circulation is a priority. Acute pain may occur, but is not a priority at this time. Tissue integrity is not impaired.

Which criterion is a clinical manifestation of sepsis?

Infection One clinical manifestation of sepsis is infection. Hypoglycemia, normal body temperature, and a systolic blood pressure of 100 mm Hg or higher are not associated with sepsis. Rather, the nurse would expect hyperglycemia, fever, and hypotension as clinical manifestations of sepsis.

When caring for a patient in acute septic shock, what should the nurse anticipate?

Infusing large amounts of intravenous (IV) fluids Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. Diphenhydramine may be used for anaphylactic shock, but would not be helpful with septic shock. VADs are useful for cardiogenic shock, not septic shock. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.

When caring for a patient with sepsis and a suspected infection, which is the priority nursing intervention?

Initiate broad spectrum antibiotics Once an infection is suspected, the nursing priority is to begin broad spectrum antibiotics therapy. Adjustments to antibiotic therapy, if needed, are based on culture results, but antibiotic therapy should not be delayed in patients with sepsis. Pain medication may be necessary but is not a nursing priority for treating infection. Blood cultures should be drawn before antibiotic therapy.

The nurse is caring for a patient who developed cardiogenic shock. Which medical diagnosis does the nurse suspect?

Myocardial infarction Myocardial infarction may produce necrotic areas of cardiac tissue that lead to impaired contractility and decreased cardiac output. This may lead to a cardiogenic shock state. Hemorrhage may lead to a hypovolemic shock state, tension pneumothorax may lead to an obstructive shock state, and urosepsis may lead to a septic shock state.

Which type of shock can be treated by minimizing spinal cord trauma with stabilization?

Neurogenic shock Neurogenic shock is caused by severe injury to the spinal cord and results in loss of sympathetic stimulation of blood vessels. Apart from administering vasoconstrictor agents, minimizing the spinal cord trauma with stabilization is a supporting therapy for neurogenic shock. Septic shock occurs in response to a systemic infection. Obtaining the cultures before starting antibiotics is appropriate care for septic shock. A life-threatening allergic reaction to a sensitizing substance causes anaphylactic shock. Avoiding exposure to allergens is supportive therapy for anaphylactic shock. Excessive loss of intravascular fluid causes hypovolemic shock. Besides restoring fluid volume, correcting the cause of fluid loss is supportive therapy. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.

The nurse is caring for a patient with a tension pneumothorax. The nurse recognizes that the symptoms of tachypnea, decreased blood pressure, and decreased urine output are caused by which type of shock?

Obstructive The nurse recognizes these as signs of obstructive shock, which is a result of a physical obstruction of blood flow; can be related to tension pneumothorax, pulmonary embolism, and cardiac tamponade. Hypovolemic shock is a result of low blood volume. Septic shock is a result of a serious infection that has compromised cellular, circulatory, and metabolic function. Anaphylactic shock is a result of hypersensitivity to a sensitizing substance.

The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning?

PaO2 60 mm Hg A PaO2 of 60 is below the normal 80 to 100 mm Hg. The patient experiencing cardiogenic shock will exhibit hypotension and tachycardia, and therefore a blood pressure of 100/56 mm Hg and heart rate of 96 would not apply. A urine output of 260 cc/8 hrs is borderline but not reportable without a continued trending pattern.

A patient diagnosed with septic shock receives aggressive fluid resuscitation. The nurse performs a passive leg raise challenge to assess which process?

Patient responsiveness to fluids Performing a passive leg raise provides the nurse with an indication of patient responsiveness to fluids. If the passive leg raise is positive, the patient is fluid-responsive and should receive additional fluids. If the passive leg raise is negative, the patient is not fluid-responsive, and a vasopressor should be started. The passive leg raise does not provide information about organ perfusion, tissue perfusion, and mean arterial pressure.

The nurse is creating a care plan to prevent infections in a patient currently receiving ventilator support for multiple organ dysfunction syndrome (MODS). Which intervention would the nurse include to most effectively reduce the chance of respiratory complications?

Place the patient in a continuous motion bed frame Continuous lateral rotation therapy via a continuous-motion bed frame is used to increase mobilization and prevent nosocomial infections in the ventilated patient. Turning the patient every two hours can also be helpful, but this is not as effective as continuous lateral rotation therapy. Increasing fluids to 3,000 mL may lead to other complications and is not the best choice in this situation. While breathing treatments can also be helpful, continuous lateral rotation therapy is the most effective choice.

Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care?

Pulmonary artery pressure (PAP) 28/14 mm Hg Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be caused by the MI. The CI, CVP, and MAP readings are normal.

Which manifestation in a patient with systemic inflammatory response syndrome (SIRS) suggests respiratory system dysfunction?

Refractory hypoxemia In a patient with SIRS, refractory hypoxemia suggests respiratory system dysfunction. Other manifestations of respiratory system dysfunction include pulmonary hypertension, decreased compliance, and increased minute ventilation.

What occurs when the inflammatory response is activated in a patient with systemic inflammatory response syndrome (SIRS)?

Release of mediators A release of mediators occurs when the inflammatory response is activated. Other changes that occur include an increase in metabolism or hypermetabolism, direct damage to the endothelium, and an increase in vascular permeability.

What organ system is often the first to show signs and symptoms in multiple organ dysfunction syndrome (MODS)?

Respiratory Inflammatory mediators have a direct effect on the pulmonary vasculature causing increased capillary permeability and eventually movement of fluid into the interstitial spaces of the lung, eventually causing alveolar edema, often making the respiratory system the first to show signs and symptoms of MODS. While MODS affects the gastrointestinal, cardiovascular, and neurologic systems as well, these systems do not as commonly exhibit manifestations of MODS first. Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care.

A nurse caring for a patient with sepsis completes an intravenous fluid infusion as ordered. Which is a goal for fluid resuscitation when caring for a patient diagnosed with sepsis?

Restore tissue perfusion The goal for fluid resuscitation is the restoration of tissue perfusion. Increasing circulating fluid volume is the goal for hypovolemic shock. Restoring blood flow to the myocardium is the goal for cardiogenic shock. Achieving and maintaining a mean arterial pressure of 65 mm Hg is the goal when using vasopressors.

Which term is used to describe persistent hypotension despite adequate fluid resuscitation requiring vasopressors along with inadequate tissue perfusion resulting in tissue hypoxia?

Septic shock Septic shock is characterized by persistent hypotension despite adequate fluid resuscitation requiring vasopressors along with inadequate tissue perfusion resulting in tissue hypoxia. Sepsis is a constellation of symptoms or a syndrome in response to an infection; it is characterized by a dysregulated patient response. Inflammation is the body's response to a microorganism. Organ dysfunction refers to the failure of an organ system in an acutely ill patient such that homeostasis cannot be maintained without intervention.

Which laboratory value may indicate, by its decrease, hepatic dysfunction in a patient with systemic inflammatory response syndrome (SIRS)?

Serum transferrin In patients with systemic inflammatory response syndrome (SIRS), hepatic dysfunction impairs protein synthesis, leading to a decrease in serum transferrin. Elimination of waste products is hampered, causing an increase in ammonia. When liver cell damage occurs, there is an elevation of liver enzymes, such as serum γ-glutamyl transferase and serum aspartate aminotransferase.

The nurse is caring for a patient who has hypovolemic shock. Which medical diagnosis does the nurse suspect?

Severe burns Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. Insect bites may lead to an anaphylactic shock state. Pulmonary embolism may lead to an obstructive shock state, and myocardial infarction may lead to a cardiogenic shock state.

Which drug causes arterial and venous dilation?

Sodium nitroprusside Sodium nitroprusside acts by dilating both the arteries and veins. It is used in the treatment of cardiogenic shock. Dopamine has inotropic activity. It increases the force of the heartbeat and is used in the treatment of cardiogenic shock. Vasopressin is a vasoconstrictor used mainly in the treatment of septic shock. Phenylephrine acts by constricting the peripheral nerves and is used in the treatment of neurogenic shock. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Which assessment findings make the nurse suspect cardiovascular dysfunction in a patient with systemic inflammatory response syndrome (SIRS)?

The patient has skin mottling. Skin mottling is a sign of cardiovascular dysfunction in a patient with systemic inflammatory response syndrome (SIRS). This mottling occurs because the patient skin is perfusing, which does not consume much oxygen, while blood is shunted away from other areas. If the patient is lethargic, the nurse should suspect neurologic dysfunction rather than cardiovascular dysfunction. The nurse should suspect cardiovascular dysfunction if the patient is warm, not cold. Severe dyspnea in a patient with SIRS indicates the development of acute respiratory distress syndrome rather than cardiovascular dysfunction.

For a patient to be diagnosed with multiple organ dysfunction syndrome (MODS), how many organ systems must be simultaneously failing?

Two MODS is the failure of two or more organ systems in an acutely ill patient such that homeostasis cannot be maintained without intervention. Three, four, or five organ systems failing are more than necessary for a MODS diagnosis.

Multiple organ dysfunction syndrome (MODS), a complication of sepsis, is the failure of how many organ systems?

Two or more Multiple organ dysfunction syndrome is the failure of two or more organ systems in an acutely ill patient for whom homeostasis cannot be maintained without intervention. It is not the failure of all systems. One or more is below the threshold for the definition, and three or more is included in the stipulation of two or more.