Med Surg 3 Exam 2

A 45-year-old male is visiting the wellness clinic and has been newly diagnosed as a stage I hypertensive patient. His blood pressure assessment over the past 6 months has consistently been 145/92 mm Hg. The patient asks, "What is blood pressure?" What is the best response by the nurse?

"A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against." The contractile force of the heart is the driving pump behind blood flow through the cardiovascular system. The ease of blood flow is a measurement of diameter of the vessel (resistance) and the volume and viscosity of blood through the cardiovascular circuit

As part of a community wide flu vaccination program for older adults, the nurse is assisting at the vaccination clinic. What question should the nurse ask prior to administering the vaccine?

"Do you have any food allergies?" An allergy to eggs is a contraindication to receiving flu vaccine grown in chick embryo cells.

Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, "None of these doctors has done anything to help." Which client statement is cause for greatest concern?

"I'm so sick of this pain. I think I'm going to find a way to end it." This statement is a veiled suicide threat, and clients with pain disorder and depression have a high risk for suicide.

A client's family member comes to the nurse's station and says, "He needs more pain medicine. He is still having a lot of pain." What is the nurse's best response?

"Please tell him that I will be right there to check on him." Responding to the client and family in a timely fashion is important. Next, directly ask the client about the pain and perform a complete pain assessment. This information will determine which action to take next

When checking a patient's pulmonary artery occlusion pressure, the nurse inflates the balloon as ordered, not inflating the balloon for more than 8 to 10 seconds. The patient asks the rationale behind the nurse's actions. Which statement should the nurse make?

"Prolonged inflation can obstruct blood flow, resulting in ischemia." Prolonged inflation of the pulmonary artery catheter balloon will compromise blood flow forward of the balloon, risking pulmonary infarction

The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a prescription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication. The client begs, "Please don't stop the morphine. My pain is really a lot worse today than it was yesterday." What is the best response?

"Show me where your pain is and describe how it feels compared with yesterday." Assessing the pain is the priority in this acute care setting because there is a risk of infection or hemorrhage

The nurse is orienting a new RN to the ICU. The nurse begins to review orders recently entered by the cardiologist and to explain their rationale to the new RN. Medication orders include dobutamine (Dobutrex) 400 mg in 250 mL 5% dextrose in water titrated to keep cardiac index >2 L/min/m2. Which statement by the new RN indicates that teaching has been effective?

"The cardiac index is the measurement specific to the patient's size or body area." Cardiac index is cardiac output individualized to a patient's body surface area or size. Cardiac output is the amount of blood pumped out by a ventricle per minute. The amount of blood ejected with each ventricular contraction is stroke volume. The pressure created by the volume of blood in the left heart is pulmonary artery occlusive pressure.

The nurse is educating a new RN on preparing a patient for assessment of cardiac output using an esophageal monitor. Which statement by the new RN indicates that teaching was effective?

"The procedure involves a thin probe inserted into the esophagus." The procedure involves insertion of a thin silicone probe into the distal esophagus. The probe is easily placed similarly to an orogastric or nasograstric tube, so patients require little to no sedation. The procedure provides an immediate assessment of left ventricular performance. There are several contraindications to the procedure, including esophageal stricture and esophagegeal varices

Family members are encouraging the client to "tough out the pain" rather than risk drug addiction to opioids. The client is stoically abiding. The nurse recognizes that the sociocultural dimension of pain is the current priority for the client. Which question will the nurse ask?

"What do you believe about pain medication and drug addiction?" Beliefs, attitudes, and familial influences are part of the sociocultural dimension of pain

Minimum urine output per hour

0.5 mL/kg/hour

Normal urine output

1 mL/kg/hour

The nurse is caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells the nurse that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3 F (37.9 C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mmHg. The abdomen is rigid and tender to the touch. The nurse decides to notify the client's provider. Place the following report information in the correct order according to the SBAR (situation, background, assessment, recommendation) format.

1. "Dr. S, this is Nurse J from unit X. I'm calling about Mr. D, who is reporting severe abdominal pain." 2. "He had abdominal surgery yesterday. He is on morphine via patient-controlled analgesia, but he says the pain is getting progressively worse." 3. "He is restless and anxious: temperature is 100.3 F (37.9 C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mmHg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." 4. "I have tried to make him comfortable, and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation." 5. "Would you like to give me an order for any laboratory tests or additional therapies at this time?"

Supervision skills

1. Direction/guidance- clear, concise, specific directions; expected outcome; time frame; limitations; verification of assignment 2. Evaluation/monitoring- frequent check in; open communication lines; achievement of outcome 3. Follow up- communication of evaluation findings to the LPN or UAP and other appropriate personnel; need for teaching or guidance

Five rights of delegation

1. Right task: is this a task that can be delegated by a nurse? 2. Right circumstance: considering the setting and available resources, should delegation take place? 3. Right person: is the task being delegated by the right person to the right individual? 4. Right direction/communication: is the nurse providing a clear, concise description of the task, including limits and expectations? 5. Right supervision: once the task has been delegated, is appropriate supervision maintained?

Normal MAP

> 70-105 mmHg

A RN who is the charge nurse for the shift is making assignments for the day. Which client should be assigned to the LPN/LVN?

A 3-day postoperative client who will be discharged tomorrow morning The 3-day postoperative client who will be discharged tomorrow is stable. The client's outcomes are almost met. The LPN/LVN could provide the care for this client

The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern?

A 35-year-old opioid-naive adult will receive a basal dose of morphine via IV patient-controlled analgesia (PCA) The nurse would consider questioning all of the medication prescriptions, but the opioid-naive adult has the greatest immediate risk, because use of a basal dose has been associated with an increased incidence of respiratory depression in opioid-naive clients

For which of these clients is IV morphine the first-line choice for pain management?

A 56-year-old client reports breakthrough bone pain related to multiple myeloma The client with cancer needs morphine for symptom relief

The nurse is working with a health care provider who prescribes opioid doses based on a specific pain intensity rating (dosing to the numbers). Which client circumstance is cause for greatest concern?

A 73-year-old frail female client with a history of chronic obstructive pulmonary disease is prescribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10 According to the American Society for Pain Management Nursing, prescribing opioid medication based solely on pain intensity should be prohibited because there are many other factors to consider (e.g., age, health conditions, medication history, respiratory status). Age, small body mass, and underlying respiratory disease put the 73-year-old client at greatest risk for overmedication and respiratory depression

An RN is about to make first rounds after receiving an intershift report at 3:00 p.m. In what order should the RN see the following clients?

A client who arrived 30 minutes ago from the postanesthesia care unit A client with pneumonia who has received two doses of IV antibiotics and has an oxygen saturation of 93% A 54-year-old client 4 hours post cardiac catheterization who has mild discomfort at the access site A client who is ready for discharge but will not have available transportation home until 5:00 p.m. A client newly diagnosed with diabetes mellitus who needs reinforcement of sick-day management guidelines Priority setting can be implemented using a variety of models. The client who is postoperative should be seen first because the client is newly arrived on the unit and is at greatest risk of becoming unstable or experiencing a change in clinical condition. The client with pneumonia should be seen next because the infection involves the airway, although oxygen saturation levels are higher than the critical value of 90% or less. The client who is 4 hours post cardiac catheterization should be seen next to evaluate the site and conduct general assessment of the affected extremity. The client who will be discharged should be seen next to determine that there are no last-minute needs or issues. The client who needs teaching should be seen last because this is not a physiological need

The registered nurse must delegate aspects of care for an assigned client to a UAP for the shift. Which client would be best to delegate to the UAP?

A client who was transferred from the critical care unit 3 days ago and is ambulatory Factors to consider when delegating care include complexity of task, problem-solving innovation required, unpredictability, and level of client interaction. The ambulatory client is the best to delegate because this client is likely to be stable with a low level of unpredictability

An obstetric nurse is floated to a medical unit to care for a group of acutely ill clients. The charge nurse should assign which group of clients to the float nurse?

A client with a 3-day-old total knee replacement, a client who is postoperative for colectomy, and a client who is postoperative for hysterectomy The float nurse from the obstetrics unit can be assigned clients who have abdominal surgery, since the nurse likely has experience working with clients having cesarean section

Which client is most likely to receive opioids for extended periods of time?

A client with progressive pancreatic cancer Cancer pain generally worsens with disease progression, and the use of opioids is more generous.

Health maintenance organizations (HMOs)

A configuration of healthcare agencies that provide health maintenance and treatment services to voluntary enrollees who prepay a fixed periodic fee without regard to either in-patient or out-patient services used Geographically organized system that provides enrollees with an agreed-on package of health maintenance and treatment services

Managed care

A healthcare plan that brings delivery and financing functions into one entity in contrast to a fee for service Objective is to enhance cost containment by decreasing unnecessary services, maintain quality, facilitate management of client care needs, and promote timely and appropriate care Providers must submit written justification and request prior approval for diagnostic tests and interventions or to extend a client's length of stay

Neurogenic shock

A hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury and last up to 6 weeks. Neurogenic shock related to spinal cord injuries is generally associated with a cervical or high thoracic injury. The injury results in a massive vasodilation without compensation because of the loss of SNS vasoconstrictor tone. This massive vasodilation leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and impaired cellular metabolism

Sepsis

A life-threatening syndrome in response to an infection. It is characterized by a dysregulated patient response along with new organ dysfunction related to the infection

Leader

A person who possesses personal traits that enable him or her to personally move other constructively and ethically to positively impact client/family care or to achieve an organizational goal or vision

Quality improvement (QI)

A set of systematic and continuous actions that improve the health status of targeted client groups and delivery of healthcare services

Septic shock

A subset of sepsis. It has an increased mortality rate due to profound circulatory, cellular, and metabolic abnormalities. Septic shock is characterized by persistent hypotension, despite adequate fluid resuscitation, and inadequate tissue perfusion that results in tissue hypoxia

Shock

A syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. This results in an imbalance between the supply of and demand for O2 and nutrients

Systemic inflammatory response syndrome (SIRS)

A systemic inflammatory response to a variety of insults, including infection (referred to as sepsis), ischemia, infarction, and injury. Generalized inflammation in organs remote from the initial insult characterizes SIRS. Many different mechanisms can trigger SIRS. These include: Mechanical tissue trauma: burns, crush injuries, surgical procedures Abscess formation: intraabdominal, extremities Ischemic or necrotic tissue: pancreatitis, vascular disease, MI Microbial invasion: bacteria, viruses, fungi, parasites Endotoxin release: gram-negative and gram-positive bacteria Global perfusion deficits: postcardiac resuscitation, shock states Regional perfusion deficits: distal perfusion deficits

Team nursing

A team of nursing personnel provides total care to a group of clients; team is led by an RN (team leader) who assesses, makes nursing diagnoses, plans, implements, and evaluates care for clients on team One variation based on physical layout of nursing unit is modular nursing, in which nurses care for clients in an assigned physical area or "pod" Team leader creates work assignments based on job description, clinical expertise, and education of team members; team members retain accountability for client care and outcomes as provided by policy and law

Universal blood recipient

AB+

Manager

Accomplishes organizational goals either through personal action or directing the actions of others

According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical clients?

Acetaminophen and/or nonsteroidal antiinflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies.

Relational leadership

Acknowledges importance of relationships as cornerstone of effective leadership Connective relationships allow for better coordinated and integrated client care services in a caring, noncompetitive manner Connective leaders encourage collaboration and interpersonal skills to broker alliances

Complication of the clinical syndrome of shock often includes which of the following? Select all that apply

Acute respiratory distress syndrome Disseminated intravascular coagulation

Anaphylactic Shock

Acute, life-threatening hypersensitivity (allergic) reaction to a sensitizing substance (e.g., drug, chemical, vaccine, food, 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. Anaphylactic shock can lead to respiratory distress due to laryngeal edema or severe bronchospasm and circulatory failure from the massive vasodilation. The pt has a sudden onset of symptoms, including dizziness, chest pain, incontinence, swelling of the lips and tongue, wheezing, and stridor. Skin changes include flushing, pruritus, urticaria, and angioedema. The pt may be anxious and confused and have a sense of impending doom.

The nurse on the hospital quality improvement team has been asked to evaluate nursing care on the nurse's assigned unit. After deciding to ask the nursing staff for assistance in this effort, what would be most appropriate for the nurse to initially ask the staff to do?

Administer a client and family satisfaction survey Client satisfaction surveys are an important tool to monitor and evaluate client and family needs. This information helps healthcare organizations meet those needs.

After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2)96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the last hour. Given this report, the nurse obtains orders for treatment that include which of the following?

Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F. Fluid volume resuscitation is a priority in patients with severe sepsis to maintain circulating blood volume and end organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated. The fever may need to be treated.

HESI hint

All types of shock can lead to systemic inflammatory response syndrome (SIRS) and result in multiple organ dysfunction syndrome (MODS)

The occupational health nurse plans injury prevention educational sessions based on the premise that:

All workers need continued education related to safety issues

Which of the following clients is at risk of injury?

An 80 year old who does not have air conditioning or fan Sweating decreases in older adults, predisposing them to heat stroke

The nurse conducting a community health education program about osteoporosis for older adults should stress that which of the following people are at risk for developing osteoporosis? Select all that apply.

An 84 year old female on daily oral prednisone for emphysema A 74 year old man who has a sedentary lifestyle A 65 year old woman who smokes one pack of cigarettes per week A 70 year old man who has three glasses of wine per day

Supervisor

An individual having authority from employer to hire, transfer, suspend, lay off, recall, assign, reward, or discipline other employees

What is the best understanding of mixed venous oxygen saturation by the nurse?

An overall picture of oxygen delivery and oxygen consumption Clinical determination of mixed venous oxygen saturation can be measured hemodynamically and provides a picture of the overall oxygen utilization by organs and tissues. Mixed venous oxygen saturation is the percentage of hemoglobin saturation in the central venous circulation, and it provides an assessment of the amount of oxygen used by the tissues.

The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN?

Applying oxygen per nasal cannula as ordered The LPN/LVN is well trained to administer oxygen per nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring the response to therapy, which includes the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy

Critical pathways

Are interprofessional plans of care Are used for diagnoses and care that can be standardized Are guides to track client progress Do not replaced individualized care

What is the best way to schedule medication for a client with constant pain?

Around-the-clock If the pain is constant, the best schedule is around-the-clock to provide steady analgesia and pain control

An inexperienced graduate nurse is reviewing the medication administration record (MAR) for a client who has a patient-controlled analgesia (PCA) pump for pain management. The new nurse compares the MAR and the HCP's prescription, and both indicate that larger doses are prescribed at night compared with doses throughout the day. Which member of the health care team should the new nurse consult first?

Ask the charge nurse if this is a typical dosage for nighttime PCA The nurse has taken the first correct step and compared the MAR to the HCP's original prescription. Because the nurse is new, the charge nurse would be the best resource. In fact, larger PCA doses are given at night to increase the interval between doses. This helps the client to rest and sleep. The nurse can contact the other members of the health care team at any time if the charge nurse is unable to help

Which task would not be appropriate for the RN to delegate to LPN/LVN or UAP?

Asking the UAP to assess and evaluate the client response to IV pain medication The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation, and evaluation). The person responsible for client assessment, diagnosis, care planning, and evaluation is the registered nurse. Assistive personnel may perform simple nursing interventions, but the RN remains responsible for analyzing the data and the client outcome.

Which type of communication is necessary to implement a democratic leadership style?

Assertive communication skills

A client has received as needed (PRN) morphine, lorazepam, and cyclobenzaprine. The UAP reports that the client has a respiratory rate of 10 breaths/min. What is the priority action?

Assess the client's responsiveness and respiratory status The UAP has correctly reported findings, but the nurse is ultimately responsible to assess first and then determine the correct action

On the first day after surgery, a client receiving an analgesic via patient-controlled analgesia pump reports that the pain control is inadequate. What is the first action that the nurse should take?

Assess the pain for location, quality, and intensity Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps

The nurse conducting a community education program about cognition in older adults should stress that:

Assessment for dementia should be part of routine physical exams

In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP?

Assisting the client with preparation of a sitz bath The UAP can assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities

Bureaucratic leadership

Based on belief that individuals are motivated by external forces; leader trusts either followers or self to make decisions; relies on organization policies and rules to identify goals and direct work flow

Democratic leadership

Based on belief that individuals are motivated by internal drives and impulses, desire active participation in decisions, and desire to get tasks done; democratic leadership promotes participation and majority rule for goal setting

Laissez-faire leadership

Based on belief that individuals are motivated by internal drives and impulses; need to be left alone to make decisions about how to complete work; leader provides no direction or facilitation

Autocratic leadership

Based on belief that individuals are motivated by power, authority, and need for approval; an autocratic leader makes all decisions, uses coercion and punishment, and is uncollegial

Transformation leadership

Based on commitment to agency's vision and focuses on promoting change; not concerned with status quo Emphasizes interpersonal relationships and inspires followers Focuses on merging leader and follower motives and values to generate followers' commitment to leader's vision Encourages followers to exercise leadership abilities Uses power to instill a belief that followers can accomplish exceptional things

Tasks that may be delegated to UAPs

Bathing Feeding Ambulating clients Attending to client safety Measuring intake and output Measuring vital signs Performing simple dressing changes Performing postmortem care Range-of-motion exercises Transferring clients, such as from bed to chair Weighing clients Performing cardiopulmonary resuscitation (if certified)

A nurse is preparing for a busy day on a medical nursing unit. Prioritize the tasks and place the options in order

Begin a unit of packed red blood cells for a client with a hematocrit of 23.2% Irrigate a nasogastric tube on a client who had a colectomy the previous day Flush a poorly draining urinary catheter on an older adult client Change a dressing on a client with an infected diabetic foot ulcer Check vital signs on a 30-year-old client with a BP of 114/68 and heart rate of 94 The first priority is the administration of a blood product to the anemic client because this client is at risk for decreased tissue perfusion. The nurse then should check the postoperative client with the nasogastric tube and irrigate the tube to ensure it is functioning properly. The urinary catheter should be flushed next; while urine will collect in the bladder at first, it will back up into the renal pelvis and kidney if not treated. The nurse then should proceed to the client with the diabetic foot ulcer because dressing changes, while not urgent, are scheduled treatments. Finally, the nurse would recheck the normal vital signs on the 30-year-old or delegate them to an unlicensed assistant

Progressive stage of shock

Begins as compensatory mechanisms fail. Changes in the patient's mental status are important findings in this stage. Patients must be moved to the ICU, if not already there, for advanced monitoring and treatment

Qualities of effective leaders

Being able to think critically, take action, take calculated risks, communicate effectively, and be believable and persuasive

Formal leadership

Bestowed by employing organization and described in a job description; it provides for influence through legitimate authority, power of position, and ability to reward and punish

Transactional leadership

Built on principles of social exchange, in which individuals expect to give and receive rewards Exchange process between leaders and followers is economic, where workers perform according to policy and procedures to maximize self-interests and rewards Leaders are most successful when they understand and meet followers' needs Exchange between leader and follower continues until exchange of performance and incentive or reward is no longer valuable Aims at maintaining equilibrium or status quo and fosters interpersonal dependence

4 main categories of shock

Cardiogenic Hypovolemic Distributive Obstructive

Clinical presentation of cardiogenic shock

Cardiovascular system: tachycardia; ↓ BP; ↓ SV, CO; ↑ SVR, PAWP, CVP; ↓ capillary refill Respiratory system: tachypnea; crackles; cyanosis Renal system: ↑ Na+ and H2O retention; ↓ renal blood flow; ↓ urine output Skin: pallor; cool, clammy Neurologic system: ↓ cerebral perfusion- anxiety, confusion, agitation GI system: ↓ bowel sounds; nausea, vomiting

Clinical presentation of neurogenic shock

Cardiovascular: bradycardia; ↓ BP; ↓ CO, CVP, SVR; ↓/↑ temperature Respiratory: dysfunction related to level of injury Renal: bladder dysfunction Skin: ↓ skin perfusion; cool or warm; dry Neurologic: flaccid paralysis below the level of the lesion; loss of reflex activity GI: bowel dysfunction

Clinical presentation of septic shock

Cardiovascular: tachycardia, ↑/↓ temperature, myocardial dysfunction, biventricular dilation, ↓ ejection fraction Respiratory: hyperventilation, crackles, respiratory alkalosis → respiratory acidosis, hypoxemia, respiratory failure, ARDS, pulmonary hypertension Renal: ↓ urine output Skin: warm and flushed → cool and mottled (late) Neurologic: change in mental status (e.g., confusion), agitation, coma (late) GI: GI bleeding, paralytic ileus Diagnostic findings: ↑/↓ WBC, ↓ platelets, ↑ lactate, ↑ blood glucose, ↑ procalcitonin, ↑ urine specific gravity, ↓ urine Na+, positive blood cultures

Clinical presentation of obstructive shock

Cardiovascular: tachycardia, ↓ BP, ↓ preload, ↓ CO, ↑ SVR, CVP Respiratory: tachypnea → bradypnea (late), shortness of breath Renal: ↓ urine output Skin: pallor; cool, clammy Neurologic: ↓ cerebral perfusion: anxiety, confusion, agitation GI: ↓ to absent bowel sounds

Clinical presentation of anaphylactic shock

Cardiovascular: tachycardia; ↑ CO; ↓CVP, PAWP; chest pain; third spacing of fluid Respiratory: shortness of breath; edema of larynx and epiglottis; wheezing; stridor; rhinitis Renal: incontinence Skin: flushing, pruritus, urticaria, angioedema Neurologic: anxiety, feeling of impending doom, confusion, ↓ LOC, metallic taste GI: cramping, abdominal pain, nausea, vomiting, diarrhea Diagnostic findings: sudden onset, history of allergies, exposure to contrast media

Clinical presentation of hypovolemic shock

Cardiovascular: tachycardia; ↓ preload; ↓ CO, CVP, PAWP; ↑ SVR; ↓ capillary refill Respiratory: tachypnea → bradypnea (late) Renal: ↓ urine output Skin: pallor; cool, clammy Neurologic: ↓ cerebral perfusion- anxiety, confusion, agitation GI: absent bowel sounds Diagnostic findings: ↓ hematocrit; ↓ hemoglobin; ↑ lactate; ↑ urine specific gravity; changes in electrolytes

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy?

Central venous pressure >8 mm Hg Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater. Additional therapeutic end points include a heart rate at less than 110 beats/min and a mean arterial blood pressure at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be <2.2 mEq/L.

HESI hint

Change causes anxiety. An effective nurse change agent uses problem-solving skills to recognize factors such as anxiety that contribute to resistance to change and uses decision making and interpersonal skills to overcome that resistance. Interventions that demonstrate these skills include seeking input, showing respect, valuing opinions, and building trust.

Lifespan considerations: children

Children are better able to compensate for circulatory dysfunction than adults, and the child with shock may appear to be hemodynamically stable. A weak cry or poor tone may indicate altered cerebral perfusion.

The nurse is assessing a client who has been receiving opioid medication via patient-controlled analgesia. What is an early sign that alerts the nurse to a possible adverse opioid reaction?

Client is more difficult to arouse Most adverse opioid events are preceded by an increased level of sedation

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation?

Client on the second postoperative day who needs pain medication before dressing changes Client who is reporting pain at the site of a peripheral IV line Client with a kidney stone who needs frequent as needed (PRN) pain medication The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage

The nurse recognizes that there are ethical considerations in helping clients to achieve relief from pain. Which nursing action is the best example of the principle of nonmaleficence?

Client seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication Nonmaleficence is to prevent harm. If the client is excessively sedated, the nurse knows that giving additional opioid medication could do more harm than good, so the nurse would conduct further assessments and seek alternative options for pain relief.

Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration?

Client who is having an acute myocardial infarction with severe chest pain The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain and increase venous capacitance

Which clients must be assigned to an experienced RN?

Client who was in an automobile crash and sustained multiple injuries Client who has returned from surgery and has a chest tube in place Client with a severe headache of unknown origin Client with chest pain who has a history of arteriosclerosis These clients should be assigned to an experienced RN because all have acute conditions that require close monitoring for any developing complications

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader?

Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone Client who underwent a toe amputation and has diabetic neuropathic pain Client with arthritis who needs scheduled pain medications and heat applications The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN.

In application of the principles of pain treatment, what is the first consideration?

Client's perception of pain must be accepted The client must be believed, and his or her experience with pain must be acknowledged as valid. The data gathered via client reports can then be applied to the other options in developing the treatment plan

The charge nurse on the night shift reports that the narcotic count is incorrect. The nurse has spoken to the responsible staff nurse and believes that substance abuse by the nurse is the cause. If substance abuse proves to be the cause of the incorrect count, what is the most appropriate next step?

Complete an incident report and report findings to the pharmacy and nursing administration An incident report must be completed because of the inaccurate narcotic count. Narcotics are controlled substances and fall under federal law and regulation. Both the pharmacy and nursing administration must be notified. If the staff nurse is found to be using a controlled substance, this finding must be reported to the state board of nursing. Individual state boards of nursing identify the legal boundaries of nursing practice, including disciplinary action, through nurse practice acts (which differ among the states).

The HCP has ordered a placebo for a client with chronic pain. The newly hired nurse feels very uncomfortable administering the medication. What is the first action that the new nurse should take?

Contact the charge nurse for advice and suggestions Administering placebos is generally considered unethical. (There are circumstances, such as clinical drug research where placebos are used, but clients are aware of that possibility.) The charge nurse is a resource person who can help clarify the situation and locate and review the hospital policy

A nurse is assigned to provide care for a 96 year old bed ridden patient who experiences severe pain from chronic neurological disease. She asks the nurse to please help her leave this world so her suffering will end. According to the 1994 ANA position statement about assisted suicide, the nurse should:

Contact the pain specialist The 1994 ANA position statement stresses that nurses should not participate in assisted suicide. Refusing to care for a patient could be construed as abandonment and is not necessary. Consulting a pain specialist is the correct action.

Case management

Coordinates care provided by an interprofessional team Manages resources effectively Uses critical pathways to organize care

Behaviors of effective leaders

Creating trust; inspiring and motivating employees to achieve goals; being visible to employees; treating employees with dignity and respect as unique individuals; providing guidance, assistance, and feedback to employees; and empowering employees

Mr. Elway was admitted after a myocardial infarction and has developed cardiogenic shock. Select from the following the treatment goals for cardiogenic shock. Select all that apply.

Decrease afterload Decrease preload Improve contractility

The nurse is caring for a post MI patient in ICU. It is noted that urinary output has dropped from 60-70 mL per hour to 30 mL per hour. This change is most likely due to which of the following issues?

Decreased cardiac output

Refractory stage of shock

Decreased perfusion from peripheral vasoconstriction and decreased CO worsen anaerobic metabolism. The accumulation of lactic acid contributes to increased capillary permeability and dilation. Increased capillary permeability allows fluid and plasma proteins to leave the vascular space and move to the interstitial space. Blood pools in the capillary beds due to the constricted venules and dilated arterioles. The loss of intravascular volume worsens hypotension and tachycardia and decreases coronary blood flow. Decreases coronary blood flow leads to worsening myocardial depression and a further decline in CO. Cerebral blood flow cannot be maintained and cerebral ischemia results. The patient in this stage of shock has profound hypotension and hypoxemia. The failure of the liver, lungs, and kidneys results in an accumulation of waste products, such as lactate, urea, ammonia, and CO2. The failure of 1 organ system affects several other organ systems. Recovery is unlikely in this stage. The organs are in failure and the body's compensatory mechanisms are overwhelmed.

HESI hint

Delegating to the right person requires that the nurse be aware of the qualifications of the delegatee: appropriate education, training, skills, experience, and demonstrated and documented competence

Overdelegation

Delegator becomes overwhelmed by situation and loses control by delegating authority and responsibility to delegate Tasks are delegated inappropriately; nurse cannot successfully achieve work-related goals if overwhelmed by numerous requests Tasks that are beyond their scope of practice should not be delegated to UAPs

Underdelegation

Delegator does not think that team members can perform or complete an assignment or does not transfer full authority It is crucial to develop team members who can provide complete and comprehensive client care If unable to perform tasks, team members must be directed and trained to reach appropriate skill level

Which postoperative client is manifesting the most serious negative effect of inadequate pain management?

Develops venous thromboembolism related to immobility caused by pain and discomfort Inadequate pain management for postsurgical clients can affect quality of life, function, recovery, and postsurgical complication; thus, all the manifestations are examples of negative results. However, venous thromboembolism can lead to pulmonary embolism, and this is an immediate life-threatening concern. The nurse also needs to implement interventions to resolve unsatisfied needs, fear of pain, and hopelessness related to pain and function

Obstructive shock

Develops when a physical obstruction to blood flow occurs with a decrease CO. This can be causes by restricted diastolic filling of the right ventricle from compression (e.g., cardiac tamponade, tension pneumothorax, superior vena cava syndrome). Other causes include abdominal compartment syndrome, in which increased abdominal pressures compress the inferior vena cava. This decreases venous return to the heart. Pulmonary embolism and right ventricular thrombi cause an outflow obstruction as blood leaves the right ventricle through the pulmonary artery. This leads to decreased blood flow to the lungs and decreased blood return to the left atrium. Patients have a decreased CO, increased afterload, and variable left ventricular filling pressures depending on the obstruction. Other signs include jugular venous distention and pulsus paradoxus

A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal?

Diaphoresis Diaphoresis is one of the early signs that occurs between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours after withdrawal

Causes of cardiogenic shock

Diastolic dysfunction: inability of the heart to fill (cardiac tamponade, ventricular hypertrophy, cardiomyopathy) Dysrhythmias (bradydysrhythmias, tachydysrhythmias) Structural factors (valvular stenosis or regurgitation, ventricular septal rupture, tension pneumothorax) Systolic dysfunction: inability of the heart to pump blood forward (MI, cardiomyopathy, blunt cardiac injury, severe systemic or pulmonary hypertension, myocardial depression from metabolic problems)

The nurse has received a grant to provide a community-based education series for middle-age adults. The nurse will make the greatest impact on the health of this age group if he or she focuses the series on:

Diet and exercise

What are the essential steps of effective supervision?

Direction, evaluation, and follow-up

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart?

Dobutamine (Dobutrex) Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.

Treatment modalities for the management of cardiogenic shock include (select all that apply)

Dobutamine to increase myocardial contractility Circulatory assist devices such as an intraaortic balloon pump

Informal leadership

Does not provide an official organizational title but informal leader can substantially influence others through thoughtful and convincing ideas, knowledge, status, and personal skills

A nurse plans to delegate some responsibilities of client care to a licensed practical nurse (LPN). Which task should the nurse delegate to the LPN?

Dressing changes for a client with wounds

HESI hint

Early signs of shock are agitation and restlessness resulting from cerebral hypoxia

A client is crying and grimacing but denies pain and refuses pain medication because "my brother is a drug addict and has ruined our lives." What is the priority intervention for this client?

Encourage expression of fears and past experiences This client has strong beliefs and emotions related to the issue of the brother's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears.

The nurse needs to obtain a cardiac output measurement from a patient who has just had a pulmonary artery catheter inserted. What are important interventions for ensuring accurate pressure and cardiac output measurements?

Ensure rapid injection of fluid through the injectate port. Zero reference the transducer system at the phlebostatic axis. To ensure accurate measurement, zero referencing of the transducer system is a priority action. Rapid injection of the appropriate solution will ensure more accurate readings.

A patient stung by a bee develops severe respiratory distress and faintness. The nurse prepares for immediate administration of which of the following?

Epinephrine

The nurse is caring for a young client with type 1 diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose (BG) level is 550 mg/dL (30.5 mmol/L), but she refuses insulin; however, she wants the pain medication. What is the best action?

Explain the significance of BG and insulin and then call the health care provider Explain that insulin is a priority because life-threatening ketoacidosis may already be in progress. If she is already aware of the dangers of an elevated BG level, then her refusal suggests ongoing suicidal intent and the provider should be notified so that steps can be taken to override her refusal (potentially a court order). A BG level of over 600 mg/dL is typically a criterion for transfer to intensive care, but making arrangements for transfer is time consuming, and treatment of the elevated BG should begin as soon as possible. Withholding pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of elevated BG and possible ongoing suicidal intent

Causes of hypovolemic shock- absolute hypovolemia

External loss of whole blood (hemorrhage from trauma, surgery, GI bleeding) Loss of other body fluids (vomiting, diarrhea, excessive diuresis, diabetes insipidus, diabetes)

Lifespan considerations: pregnant women

Factors affecting maternal oxygenation also affect fetal oxygenation. Priority is given to resuscitation of the mother and administration of oxygen. Nausea and vomiting may lead to dehydration and electrolyte abnormalities. Pregnant women are assessed for signs and symptoms of uterine hemorrhage

Causes of hypovolemic shock- relative hypovolemia

Fluid shifts (burn injuries, ascites) Internal bleeding (fracture of long bones, ruptured spleen, hemothorax, severe pancreatitis) Massive vasodilation (sepsis) Pooling of blood or fluids (bowel obstruction)

Relative hypovolemia

Fluid volume moves out of the vascular space into the extravascular space (e.g., intracavitary space). We call this type of fluid shift third spacing. One example of relative volume loss is fluid leaking from the vascular space to the interstitial space from increased capillary permeability, as seen in burns

Servant leadership

Focuses on desire to serve others; based on principles of caring In the desire to serve, one can be called upon to lead A servant leader seeks to address others' needs as priority Nurse leaders provide care and compassionate service to others

Quality management

Focuses on evaluating care delivery processes in order to correct problems or prevent errors in treatment to uphold client safety in a cost-effective manner

Shared leadership

Founded on principles of empowerment, participation, and transformational leadership No one person or leader possesses all knowledge and abilities Elements of shared leadership include relationships, dialogues, partnerships, and understanding boundaries Shared leadership allows for appropriate leadership to emerge as problems and issues arise (different issues call for different responses)

The client is prescribed a fentanyl patch for persistent severe pain. Which client behavior most urgently requires correction?

Frequently likes to sit in the hot tub to reduce joint stiffness Heat can increase the release of medication from the patch and result in a sudden overdose

Nursing care delivery systems

Functional nursing Relationship-based nursing (primary nursing) Team nursing

A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will the nurse advocate for first?

Gabapentin Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy

The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first?

Give praise for documenting dose and time and discuss documentation deficits In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed.

For a postoperative client, the HCP prescribed multimodal therapy, which includes acetaminophen, nonsteroidal anti-inflammatory drugs, as needed (PRN) opioids, and nonpharmaceutical interventions. The client continuously asks for the PRN opioid, and the nurse suspects that the client may have a drug abuse problem. Which action by the nurse is best?

Give the opioid because client deserves relief and drug abuse is unconfirmed The nurse is weighing benefit against harm. If client is a drug abuser, the medication given in the hospital is not harming him. If the client is not a drug abuser, then withholding the medication causes him to suffer pain because of unconfirmed suspicions. The nurse must also remember that medical use of opioids does not cause addiction and for clients who are addicted, withholding medication in the hospital setting does not resolve the addictive behavior

A 62 year old man states, "I have trouble with my peripheral vision. Sometimes, I do not notice objects unless they are in front of me." He is most likely suffering from:

Glaucoma Glaucoma is the insidious loss of peripheral vision.

Doffing PPE

Gloves Goggles or face shield Gown Mask

Donning PPE

Gown Mask Goggles or face shield Gloves

A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action?

Have a conference with the staff nurses to assess their care of this client The charge nurse must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem

Causes of neurogenic shock

Hemodynamic consequence of spinal cord injury and/or disease at or above T5: severe pain, drugs, hypoglycemia, injury Spinal anesthesia Vasomotor center depression

Team leadership style

High concern for both tasks and people

Country club leadership style

High concern for people, low concern for tasks

Authority leadership style

High concern for tasks, low concern for people

Which hemodynamic values should the nurse anticipate in a patient who is in the initial stages of septic shock state?

High heart rate; low right atrial pressure In septic shock, inflammatory mediators damage the endothelial cells that line blood vessels, producing profound vasodilation and increased capillary permeability. Initially this results in a high heart rate, hypotension, and low SVR, and subsequently in low right atrial pressure.

Causes of anaphylactic shock

Hypersensitivity (allergic) reaction to a sensitizing substance: contrast media, blood or blood products, drugs, insect bites, anesthetic agents, food or food additives, vaccines, environmental agents, latex

How to delegate

Identify a suitable person for the task who has the appropriate skill set Prepare the person. Explain the task clearly. Make sure that you are understood Make sure the person has the necessary authority to do the job properly Keep in touch with the person for support and to monitor progress while allowing sufficient time and opportunity to complete the task Retain responsibility for knowing the outcome of the delegation Praise and acknowledge a job well done

HESI hint

If cardiogenic shock exists in the presence of pulmonary edema (i.e., from pump failure), position client to reduce venous return (high fowler position with legs down) to decrease further venous return to the left ventricle. If an intraaortic balloon pump is used to decrease myocardial oxygen demand and improve myocardial perfusion, the nursing responsibilities are to assess that the balloon is inflating during diastole (spike on P wave on ECG) and that blood is not backing up into the tubing. The nurse is also responsible for assessing for potential complications of this device, such as limb ischemia, compartment syndrome, aorta dissection, plaque or emboli dislodgement, migration of the catheter, insertion site bleeding, rupture of the balloon, signs and symptoms of infection, and skin breakdown because the client has limited movement.

A UAP may perform care that falls within which component of the nursing process?

Implementation

Shock is best defined as:

Inadequate tissue perfusion

Assertive communication

Includes clearly defined goals and expectations Includes verbal and nonverbal messages that are congruent Is critical to the directing aspect of the management Starts with "I need" rather than with "You must"

Causes of septic shock

Infection: pneumonia, peritonitis, urinary tract, invasive procedures, indwelling lines and catheters At-risk patients: older adults, patients with chronic diseases (e.g., diabetes, chronic kidney disease, HF), patients receiving immunosuppressive therapy or who are malnourished or debilitated

Stages of shock

Initial stage Compensatory stage Progressive stage Refractory stage

Steps of GI assessment

Inspection Auscultation Palpation Percussion Listen for 5 minutes Normal: 4-35 per minute

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's priority concern?

Instruct the client to increase oral intake to 2 to 3 L/day An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the RN would want to know about bowel movements, dietary intake, and urine output, in this case, the priority is that the client is not taking in enough oral fluids

Quality assurance

Involves continuous quality improvement (CQI)/total quality management (TQM) Is an organized approach to the improvement of: outcome achievement and quality of care provided

The RN is assigned to five clients for the shift. Which tasks are best delegated to the LPN/LVN?

Irrigating a urinary catheter on a client admitted from a skilled nursing facility Changing a dressing on a client with a diabetic foot ulcer in the metatarsal area The scope of practice for LPNs/LVNs allows them to irrigate urinary catheters and change dressings on diabetic ulcers.

The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order?

Lactated Ringer's (LR) Normal saline LR solution and 0.9% normal saline are isotonic solutions that are commonly infused to treat hypovolemia. Solutions of 5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the administration of colloids in most patient populations.

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective?

Lactated Ringer's should not be infused if lactic acidosis is severe. LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic acidosis. However, LR should not be infused if lactic acidosis is severe.

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are

Level of consciousness, urine output, and skin color and temperature

Mean arterial pressure (MAP)

Level of pressure in the central arterial bed measured indirectly by BP measurement MAP= cardiac output x total peripheral resistance= systolic BP + 2 (diastolic BP)/3 In adults, usually approaches 100 mmHg Can be measured directly through arterial catheter insertion

A RN working on the medical unit arrives at work 15 minutes late. The nurse is assigned five clients, and an admission is on the way. Place in order of priority how the nurse should complete the following activities at the beginning of the work shift.

Listen to report Check on the status of all clients Review morning lab results, including glucose monitoring Check the medication administration record (MAR) The nurse should start the day by listening to report. This allows the nurse to receive information about the status of each client. The next action is to check the clients. The nurse should check on each assigned client to determine the current status of each client. The goal of checking each client at the beginning of the shift is to make sure distress is not present. Once the nurse has checked each client, the nurse should review AM labs. This information gives the nurse pertinent information that helps plan the day and detect subtle changes in the client's status, which allows earlier treatment and preventative interventions. Lastly, the nurse should review the MAR to detect priority medications. The laboratory results can impact the medications given, which is why they need to be checked before the MAR

Impoverished leadership style

Low concern for tasks or people

The nurse is caring for a patient in shock. Which is a priority action by the nurse?

Maintain adequate tissue perfusion. Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery.

A client has severe pain and bladder distention relation to urinary retention and possible obstruction. An experienced UAP states that she received training in indwelling catheter insertion at a previous job. What task can be delegated to this UAP?

Measuring the urine output after the catheter is inserted and obtaining a specimen Measuring output and obtaining a specimen are within the scope of practice of the UAP. Insertion of the indwelling catheter in this client should be done by an experienced RN because clients with obstruction and retention are usually very difficult to catheterize, and the nurse must evaluate the pain response during the procedure.

Middle of the road leadership style

Moderate concern for both tasks and people

HESI hint

Motivation comes from within an individual. A nurse leader can provide an environment that will promote motivation through positive feedback, respect, and seeking input. Look for responses that demonstrate these behaviors

The nurse is caring for a postoperative client who reports pain. Based on recent evidence-based guidelines, which approach would be best?

Multimodal strategies Multimodal therapies for postoperative clients include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies. This approach is thought to be the most important strategy for pain management for most postoperative clients.

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for?

Multisystem organ failure and/or dysfunction Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which contribute to multiple organ failure

Types of distributive shock

Neurogenic Anaphylactic Septic

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing

Neurogenic shock from massive vasodilation

Manifestations of compensatory stage of shock

Neurologic: oriented to person, place, time; restless, apprehensive, confused; change in LOC Cardiovascular: SNS response: release of epinephrine/norepinephrine (vasoconstriction), ↑ MVO2, ↑ contractility, ↑ HR; coronary artery dilation; narrowed pulse pressure; ↓ BP Respiratory: ↓ blood flow to the lungs: ↑ physiologic dead space, ↑ ventilation-perfusion mismatch, hyperventilation, ↑ minute ventilation (VE), tachypnea GI: ↓ blood supply; ↓ GI motility; hypoactive bowel sounds; ↑ risk for paralytic ileus Renal: ↓ renal blood flow; ↑ renin resulting in release of angiotensin (vasoconstrictor); ↑ aldosterone resulting in Na+ and H2O reabsorption; ↑ antidiuretic hormone resulting in H2O reabsorption Temperature: normal or abnormal Skin: pale and cool; warm and flushed

Manifestations of refractory stage of shock

Neurologic: unresponsive; areflexia (loss of reflexes); pupils nonreactive and dilated Cardiovascular: profound hypotension; ↓ CO; bradycardia, irregular rhythm; ↓ BP inadequate to perfuse vital organs Respiratory: severe refractory hypoxemia; respiratory failure GI: ischemic gut Renal: anuria Hepatic: metabolic changes from accumulation of waste products (e.g., NH3, lactate, CO2) Hematologic: DIC progresses Temperature: hypothermia Skin: mottled, cyanotic

Manifestations of progressive stage of shock

Neurologic: ↓ cerebral perfusion pressure; ↓ cerebral blood flow; ↓ responsiveness to stimuli; delirium Cardiovascular: ↑ capillary permeability → systemic interstitial edema; ↓ CO → ↓ BP and ↑ HR; MAP < 60 mmHg (or 40 mmHg drop in BP from baseline); ↓ coronary perfusion → dysrhythmias, myocardial ischemia, MI; ↓ peripheral perfusion → ischemia of distal extremities, ↓ pulses, ↓ capillary refill Respiratory: ARDS: ↑ capillary permeability, pulmonary vasoconstriction, pulmonary interstitial edema, alveolar edema, diffuse infiltrates, tachypnea, ↓ compliance, moist crackles GI: vasoconstriction and ↓ perfusion → ischemic gut (e.g., stomach, small and large intestines, gallbladder, pancreas): erosive ulcers, GI bleeding, translocation of GI bacteria, impaired absorption of nutrients Renal: renal tubules become ischemic → acute tubular necrosis; ↓ urine output; ↑ BUN-to-creatinine ratio; ↑ urine sodium; urine osmolality and specific gravity; ↓ urine potassium; metabolic acidosis Hepatic: failure to metabolize drugs and waste products; cell death (if ↑ liver enzymes); jaundice (↓ clearance of bilirubin); ↑ NH3 (ammonia) and lactate Hematologic: DIC: thrombin clots in microcirculation; consumption of platelets and clotting factors Temperature: hypothermia or hyperthermia Skin: cold and clammy

The charge nurse of a long-term care facility is reviewing the methods and assessment tools that the staff nurses are using to assess pain. Which nurse is using the best method to assess pain?

Nurse C uses the same numerical rating scale every day for the same client Pain assessment is very complex, but the consistent use of the same assessment tool is the best method.

Right circumstances

Nurse evaluates individual clients and UAPs and matches the two. Nurses assesses client's needs, looks at care plan, considers the setting, and ensures that UAPs have proper resources, equipment, and supervision to work safely

Right person

Nurse follows organizational policies, which are congruent with state law, in determining appropriate staff to which to delegate a nursing activity

Right supervision and evaluation

Nurse managers ensure that each unit has adequate staffing and time, identify tasks inherent to each staff role, and evaluate impact of organization's nursing service on the community. Delegating nurse must supervise, guide, and evaluate UAP's task implementation, ensure that UAPs meet expectations, and intervene if not performing well

Right direction and communication

Nurse needs to clearly understand organization's policies and procedures to carry out effective delegation. (Nurse needs to direct UAP's actions and communicate clearly about each delegated task, being specific about how and when UAPs should report back to them.) Nurse should feel comfortable asking, Do you know how to do this? Where did you learn? How many times have you done it in the past? Where is your experience documented?

Right task

Nurses determine those activities team members may perform. For each situation, nurse must consider stability of client's condition, complexity and safety of activity, UAP's capabilities, and amount of supervision nurse can provide

A quarterly audit is now due to evaluate implementation of an electronic medical record system on the nursing unit. As the unit representative who supervised the adaptation of this documentation system, how can the nurse best determine if nursing staff have accepted this change?

Nursing staff uses the electronic medical record daily in routine documentation When people accept change, they integrate it into their daily routines and the change is maintained.

Universal blood donor

O-

For a cognitively impaired client who cannot accurately report pain, what is the first action that the nurse should take?

Obtain baseline behavioral indicators from family members Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this observation is not obtained, the nursing staff must rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns

Hypovolemic shock

Occurs from inadequate fluid volume in the intravascular space to support adequate perfusion. The volume loss may be either an absolute or a relative volume loss

Cardiogenic shock

Occurs when either systolic or diastolic dysfunction of the heart's pumping action results in reduced cardiac output (CO), stroke volume (SV), and BP. These changes compromise myocardial perfusion, further depress myocardial function, and decrease CO and perfusion

Which client is at greatest risk for respiratory depression while receiving opioids for analgesia?

Opioid-naive adolescent with an arm fracture and cystic fibrosis At greatest risk are older adult clients, opiate-naive clients, and those with underlying pulmonary disease. The adolescent has two of the three risk factors

Case management

Organizes client care by major diagnoses and focuses on attaining predetermined client outcomes within specific time frames Advantages: all professionals are equal members of team; emphasis is on managing interdisciplinary outcomes; promotes continuity of care Disadvantages: requires essential baseline data be available to team members; job descriptions of case managers vary among institutions

Organizational skills encompass management of

People Time Supplies

For followers to grow and flourish, nurse leaders must provide:

Personal attention: support and guidance in foreseeing problems and challenges Role modeling: encouragement of self-management, assessment, openness, and forthrightness Precepting: to assist, approach, and coach in a timely and appropriate manner Mentoring: to invest by sharing expertise and experience with others

Causes of obstructive shock

Physical obstruction impeding the filling or outflow of blood resulting in decreased CO: cardiac tamponade, tension pneumothorax, superior vena cava syndrome, abdominal compartment syndrome, pulmonary embolism

A client is experiencing respiratory distress. Respirations are 32 breaths/min and shallow. The client is positioned in an orthopneic position, with a heart rate of 118/min and a blood pressure of 90/40 mmHg. The client is pale and confused. Which task should the nurse delegate to the charge nurse?

Placement of a second IV site The charge nurse should be used to complete a task within the RN's scope or practice, such as starting an IV line, while leaving client assessment to the assigned nurse.

What is the best action by the nurse to level and zero a hemodynamic monitoring system transducer?

Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line). To obtain accurate hemodynamic values, the transducer system must be positioned at the level of the atria and pulmonary artery, commonly termed the phlebostatic axis (fourth intercostal space, midaxillary line). The transducer must be leveled at the phlebostatic axis. The transducer must be placed at the level of the fourth intercostal space, midaxillary line.

What is the best action by the nurse to accurately record a thermodilution cardiac output (CO)?

Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output. The average of three cardiac output measurements, all within 10% of each other, is obtained to accurately assess a cardiac output. To obtain accurate cardiac output measurements, a patient must be in the supine position with a backrest elevation of 0 to 30 degrees. Three successive measurements are taken and the average cardiac output calculated.

Central venous pressure (CVP)

Pressure within the right atrium; normal CVP/RAP ranges from 2-6 mmHg

Relationship-based nursing (primary nursing)

Primary nurse designs, implements, and is accountable for nursing care of clients from admission through discharge; care is carried out by associate nurses when primary nurse is off duty Decentralizes nursing care decisions, authority, and responsibility to level of staff nurse; decreases number of unlicensed personnel; enhances family satisfaction with care; and maintains high level of accountability Requires excellent communication between nurses; may be costly for institutions to hire highly skilled nurses

HESI hint

Priorities often center on which client the nurse should assess first. Ask yourself: which client is the most critically ill and unstable? Which client is most likely to experience a significant change in condition? Which client requires assessment by an RN?

Skills needed by change agents

Problem solving Decision making Interpersonal relationships

The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to the UAP?

Providing straws and offering fluids between meals UAPs can reinforce additional fluid intake when it is part of the care plan

HESI hint

RNs should give clear instructions- be specific, communicating the objectives of the delegated task and the expected results Remember than even though a task may be delegated under law and facility policy, you, the nurse, are responsible for its outcome

When discussing sexuality with middle-age men and women, the nurse should stress that:

Rates of new HIV infection in middle-age people is higher than in other age groups

After receiving the intershift report, the RN has many tasks to complete during the next 12 hours. Which tasks should the nurse delegate to a UAP?

Rechecking vital signs on a 30-year-old client with a BP of 100/60 Measuring and recording hourly urine output for a client who underwent nephrectomy The UAP can measure vital signs and report the findings to the RN. The UAP can measure and record the urine output, although the RN would need to make further assessments about the client's status.

The nurse is caring for a patient who is being monitored with a central venous catheter. In preparing to record a right atrial pressure reading, what is most important for the nurse to keep in mind when recording an accurate value?

Record the pressure at the end of expiration. Right atrial pressures are measured at the end of expiration to ensure that pleural pressure changes do not skew the numerical value.

HESI hint

Remember the nursing process: assessments, analysis, diagnosis, planning, and evaluation (any activity requiring nursing judgment) may not be delegated to UAP. Delegated activities fall within the implementation phase of the nursing process

A nurse is preparing for the shift, and makes a list of delegated tasks for the UAP. Which task should the nurse delegate to the UAP?

Repositioning a client with severe weakness caused by multiple sclerosis

Functional nursing

Represents a task approach to care that is coordinated by charge nurse; client needs are defined by activities delegated to RNs, LPNs/LVNs, and UAPs This system results in fragmentation of care and lack of a holistic view of client

Peripheral resistance (PR)

Resistance to blood flow offered by the vessels in the peripheral vascular bed

When caring for a seriously ill patient, the nurse determines that the patient may be in The Compensatory stage of shock upon finding which of the following assessments?

Restlessness and apprehension

Absolute hypovolemia

Results when fluid is lost through hemorrhage, GI loss (e.g., vomiting, diarrhea), fistula drainage, diabetes insipidus, or diuresis

What are the five rights of delegation?

Right task Right circumstance Right person Right direction or communication Right supervision

Five rights of delegation

Right task Right circumstances Right person Right direction and communication Right supervision and evaluation

A 78-year-old man with a history of diabetes has confusion and temperature of 104F (40C). There is a wound on his right heel with purulent drainage. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mmHg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/min; and PAWP 4 mmHg. This patient's symptoms are most likely indicative of

Septic shock

Interprofessional health care teams require

Shared goals, commitment, and accountability Open and clear communication Respect for the expertise of all team members

The home health nurse discovers that an older adult client has been sharing his pain medication with his daughter. Despite the nurse's warnings about the dangers of sharing, he states, "My daughter can't afford to see a doctor or to buy medicine, so I must give her a few of my pain pills." Which member of the health care team is the nurse most likely to consult first?

Social worker to help the family locate resources for health care If the social worker can assist the family to find affordable alternatives, then the father is more likely to stop giving his medications to the daughter

By what authority may RNs delegate nursing care to others?

State Nurse Practice Act

Phenylephrine (Neo-Synephrine)

Stimulates alpha receptors, which causes vasoconstriction Used in vasodilatory states (distributive shock) to restore vascular tone Side effects: reflex bradycardia; ventricular dysrhythmias; hypertension; nausea, vomiting; paresthesia; palpitations; anxiety; restlessness; headache; tremor; chest pain Nursing implications: monitor HR, BP, and ECG; treat reflex bradycardia with atropine

Norepinephrine (Levophed)

Stimulates alpha receptors, which causes vasoconstriction Used in vasodilatory states (distributive shock) to restore vascular tone Stimulation of beta receptors, which ↑ contractility and HR Side effects: tachycardia; ventricular dysrhythmias; hypertension; anxiety; headache; tremor; dizziness; chest pain; metabolic (lactic) acidosis; tissue necrosis if extravasation occurs Nursing implications: monitor BP, HR, ECG, urine output, and neurologic status; treat extravasation with phentolamine (Regitine); do not administer with alkaline solutions

Dobutamine (Dobutrex)

Stimulates primarily beta1 receptors to increase contractility and increase HR and causes vasodilation in low-CO states Side effects: tachycardia; dysrhythmias; hypotension; nausea, vomiting; dyspnea; headache; anxiety; paresthesia; palpitations; chest pain Nursing implications: monitor BP, HR, ECG, PAP, PAOP, SVR, CO, and CI; use cautiously in patients with HTN, myocardial ischemia, or ventricular dysrhythmias; replace volume before initiation of infusion; do not administer with alkaline solutions

A nurse is assisting a client in room 1 with lunch. The charge nurse calls the nurse and states the client in room 3 is reporting pain and requests pain medication. What is the nurse's best and first action?

Stop feeding the client in room 1, and medicate the client in room 3 for pain The nurse should stop feeding the client in room 1, and medicate the client in room 3 as the priority action. While eating is a priority, it does not take precedence over an individual with pain. The client in pain is experiencing discomfort that should be addressed immediately

What is the best position for the nurse to place the patient in to obtain a right atrial pressure measurement?

Supine, either flat or with the head of the bed no more than 60 degrees Accurate assessment of a hemodynamic measure is best accomplished with the patient in a supine position with the head of the bed elevated slightly but no more than 60 degrees.

A nurse has delegated a venipuncture to an unlicensed assistant (UAP) who has been off orientation for 5 days. The UAP reports, "This client has a large, raised red area where the needle was inserted." The nurse's subsequent assessment reveals a hematoma in the venipuncture area. What elements of delegation have been breached?

Task Supervision Skill The nurse assigned a task at which the UAP evidently was weak, and did not provide supervision. The nurse has delegated a venipuncture to a UAP who may or may not be comfortable providing the skill. Though the task is permissible in general, venipuncture is not the right task for this UAP

Reverse delegation

Team member requests that nurse complete task because of inability or unwillingness to perform designated task or procedure Minimize reverse delegation with use of competency-based orientation programs and in-service or staff development classes

The client is diagnosed by the emergency department HCP with an acute migraine. For which situation is it most important to have a discussion with the HCP before medication is prescribed?

The HCP is considering subcutaneous sumatriptan, and the client took ergotamine 3 hours ago The American Headache Society developed recent guidelines for treatment of acute migraines. Intravenous metoclopramide and prochlorperazine and subcutaneous sumatriptan are recommended for adults who present with first-time onset of acute migraines. Sumatriptan should not be used if ergotamine, dihydroergotamine, or other triptan medication has been used in the past 24 hours because of the additive effect of narrowing of the blood vessels that could result in damage to major organs (e.g., stroke or myocardial infarction)

HESI hint

The RN is accountable for adhering to the three basic aspects of supervision when delegating to other health care personnel, such as LPNs, graduate nurses, inexperienced nurses, student nurses, and UAP

Compensatory stage of shock

The body activates neural, hormonal, and biochemical compensatory mechanisms to try to overcome the increasing consequences of anaerobic metabolism and maintain homeostasis. The patient's clinical presentation begins to reflect the body's responses to the imbalance in O2 supply and demand. A classic sign of shock is a drop in BP. This occurs because of a decrease in CO and a narrowing of the pulse pressure. The baroreceptors in the carotid and aortic bodies immediately respond by activating the SNS. The SNS stimulates vasoconstriction and the release of the potent vasoconstrictors epinephrine and norepinephrine. Blood flow to the heart and brain is maintained. Blood flow to the nonvital organs, such as kidneys, GI tract, skin, and lungs, is diverted or shunted. The myocardium responds to the SNS stimulation and the increase in O2 demand by increasing the HR and contractility. Increased contractility increases myocardial O2 consumption. The coronary arteries dilate to try and meet the increased O2 demands of the myocardium. Shunting blood away from the lungs has an important clinical effect in the patient in shock. Decreased blood flow to the lungs increases the patient's physiologic dead space. Physiologic dead space is the anatomic dead space (the amount of air that will not reach gas-exchanging units) and any inspired air that cannot take part in gas exchange. The clinical result of an increase in dead space ventilation is a ventilation-perfusion mismatch. Some areas of the lungs that are being ventilated will not be perfused because of the decreased blood flow to the lungs. Arterial O2 levels will decrease, and the patient will have a compensatory increase in the rate and depth of respirations. The shunting of blood from other organ systems results in clinically important changes. The decrease in blood flow to the GI tract results in impaired motility and a slowing of peristalsis. This increases the risk for a paralytic ileus. Decreased blood flow to the skin results in the patient feeling cool and clammy. The exception is the patient in early septic shock who may feel warm and flushed because of a hyperdynamic state. Decreased blood flow to the kidneys activates the renin-angiotensin system. Renin stimulates angiotensinogen to make angiotensin I, which is then converted to angiotensin II. Angiotensin II is a potent vasoconstrictor that causes both arterial and venous vasoconstriction. The net result is an increase in venous return to the heart and an increase in BP. Angiotensin II stimulates the adrenal cortex to release aldosterone. This results in sodium and water reabsorption and potassium excretion by the kidneys. The increase in sodium reabsorption raises the serum osmolality and stimulates the release of antidiuretic hormone (ADH) from the posterior pituitary gland. ADH increases water reabsorption by the kidneys, further increasing blood volume. The increase in total circulating volume results in an increase in CO and BP. A multisystem response to decreasing tissue perfusion starts during the compensatory stage of shock. At this stage, the body can compensate for the changes in tissue perfusion. If the cause of the shock is corrected, the patient will recover with little or no residual effects. If the cause of the shock is not corrected and the body is unable to compensate, the patient enters the progressive stage of shock

Fluid resuscitation

The cornerstone of therapy for septic, hypovolemic, and anaphylactic shock is is volume expansion with administration of the appropriate fluid. Fluid resuscitation should start using 1 or 2 large-bore (e.g., 14 to 16-gauge) IV catheters, an intraosseous (IO) access device, or a central venous catheter

Lifespan considerations: older adults

The effects of aging diminish the body's ability to tolerate shock states. Older adults are at greater risk for dehydration, infection, sepsis, and anaphylaxis. As the body ages, the left ventricular wall thickens, ventricular compliance decreases, and calcification and fibrosis of the heart valves occur. Stroke volume and cardiac output are reduced. There is a decreased sensitivity of the baroreceptors and a diminished HR response to SNS stimulation in the early stage of shock. Older adults are more likely to be prescribed beta blockers medication, which also decreases the HR response. Arterial walls lose elasticity, increasing SVR, which increases the myocardial oxygen demand and decreases the responsiveness of the arterial system to the effects of catecholamines. Aging decreases lung elasticity, alveolar perfusion, and alveolar surface area and causes thickening of the alveolar-capillary membrane. These changes limit the body's ability to increase blood oxygen levels during shock states. The ability of the kidney to concentrate urine decreases with age, which limits the body's ability to conserve water when required. The immune system loses effectiveness with age, increasing the risk of infection and sepsis, especially with illness, injury, or surgery. Older adults are also at greater risk for anaphylaxis because they have been exposed to more antigens and therefore have antibodies to more antigens. Decreased skin turgor makes assessment of fluid status difficult. Dehydration is common and may increase the risk for hypovolemia.

The staff nurse who is in charge of the medical-surgical unit for the shift is receiving four admissions. The emergency department is sending a client with hypertension and an exacerbation of heart failure, and a client who has pneumonia and a history of diabetes mellitus. The post-anesthesia care unit (PACU) is transferring a client who had a total abdominal hysterectomy and a client who underwent hip replacement. If the staff consists of two RNs (one on orientation) and two LPNs, what assignment would be appropriate?

The experienced RN will be assigned the postoperative client who underwent hip replacement Of the answer options, the best option is that the skilled RN should get the postoperative client with the hip replacement and the abdominal hysterectomy. Postoperative clients are critical clients due to the risk for hypovolemia and shock. The experienced nurse should receive the surgical clients

Multiple organ dysfunction syndrome (MODS)

The failure of 2 or more organ systems in an acutely ill patient such that homeostasis cannot be maintained without intervention. MODS results from SIRS. These 2 syndromes represent the ends of a continuum. Transition from SIRS to MODS does not occur in a clear-cut manner

Systolic dysfunction

The heart's inability to pump the blood forward Results in a low CO (<4 L/min) and cardiac index (<2.5 L/min) Primarily affects the left ventricle since systolic pressure is greater on the left side of the heart Most common cause: acute MI When systolic dysfunction affects the right side of the heart, blood flow through the pulmonary circulation is reduced Decreased filling of the heart results in decreased SV

HESI hint

The nurse manager must analyze all the desired outcomes involved when assigning rooms for clients or assigning client care responsibilities. A client with an infection should not be assigned to share a room with a surgical or immunocompromised client. A nurse's client care management should be based on the nurse's abilities, the individual client's needs, and the needs of the entire group of assigned clients. Safety and infection control are high priorities.

Supervision

The provision of guidance or direction, evaluation, and follow-up of nursing personnel for accomplishment of a delegated nursing task; staff nurses are responsible for supervision of care they delegate to other nursing team members; nurses also need to recognize situations in which there is a need to contact shift supervisor for assistance

Initial stage of shock

This stage is usually not clinically apparent. Metabolism changes at the cellular level from aerobic to anaerobic, causing lactic acid buildup. Lactic acid is a waste product that is removed by the liver. However, this process requires O2, which is unavailable because of the decrease in tissue perfusion

When an analgesic is titrated to manage pain, what is the priority goal?

Titrate to the smallest dose that provides relief with the fewest side effects The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside

Delegation

Transferring to a competent individual authority to perform a selected nursing task in a selected situation

A nurse is delegating care of clients to an unlicensed assistant (UAP) and LPN/LVN. Which tasks should the nurse give the UAP and LPN/LVN?

UAP: measure vital signs; LPN/LVN: give oral medications on assigned clients

HESI hint

Unlicensed assistive personnel (UAP) generally do not perform invasive or sterile procedures

The home health nurse is interviewing an older client with a history of mild heart failure and rheumatoid arthritis. The client reports "feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed." Which member of the health care team would be the most appropriate to aid in the client's report of pain?

Unlicensed assistive personnel to help client with a warm shower in the morning One of the most common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A nonpharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions.

The nurse evaluates that fluid resuscitation for a patient in shock is effective upon finding that patient assessment includes which of the following?

Urine output is 1mL/kg/hr

Safety alert: intraosseous (IO) access

Use an IO access device for emergency resuscitation when IV access cannot be obtained Insertion sites include the sternum, proximal and distal tibia, and proximal and distal humerus Remove IO devices within 24 hours of insertion or as soon as possible after peripheral or central IV access is obtained Monitor for complications: extravasation of drugs and fluids into the soft tissue, fractures caused during insertion, and osteomyelitis

Epinephrine

Used in hypotensive states to produce constriction of vascular smooth muscle Promotes bronchodilation in anaphylactic shock Side effects: chest pain; hypertension; tachycardia; pulmonary edema; dyspnea; anxiety Nursing implications: monitor HR, BP, ECG, and chest pain; assess and correct volume depletion before and during administration; monitor infusion site for blanching or extravasation; treat extravasation with phentolamine (Regitine)

Dopamine (Intropin)

Used in low-CO states or vasodilatory states (distributive shock) to restore vascular tone Dose-dependent effect: at 2-10 mcg/kg/min stimulates beta1 receptors, which ↑ contractility and HR; at 10-20 mcg/kg/min stimulates alpha receptors, which causes vasoconstriction and ↑ SVR Side effects: tachycardia; dysrhythmias; nausea, vomiting; dyspnea; headache; palpitations; chest pain in patients with coronary artery disease; tissue necrosis if extravasation occurs Nursing implications: monitor HR, BP, ECG, PAP, PAOP, SVR, CO, CI, and urine output; treat cause of ↓ BP before initiating (e.g., hypovolemia treated with fluid resuscitation); wean slowly; treat extravasation with phentolamine (Regitine); do not administer with alkaline solutions

Vasopressin

Vasoconstriction through smooth muscle contraction of all parts of capillaries, arterioles, and venules Used in vasodilatory states (distributive shock) to restore vascular tone Side effects: ↓ HR; ↑ BP; fever; hyponatremia; abdominal cramps; tremor; headache; seizures; coma; chest pain and myocardial ischemia

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for?

Vasodilation In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment?

Vasodilation and relative hypovolemia. Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that result in a relative hypovolemia.

Nitroprusside (Nipride)

Vasodilation by direct smooth muscle relaxation, predominantly arterial Used in preload and/or afterload reduction (cardiogenic shock) Side effects: nausea, vomiting; abdominal pain; headache; tinnitus; dizziness; diaphoresis; apprehension; hypotension; tachycardia; palpitations; hypoxemia (from nitroprusside-induced intrapulmonary thiocyanate toxicity) Nursing implications: monitor HR, BP, urine output, and neurologic status; monitor for patient thiocyanate toxicity (metabolic acidosis, confusion, hyperreflexia, and seizures); serum thiocyanate levels drawn daily if drug is used longer than 72 hr; treatments includes amyl nitrate, sodium nitrate, and/or sodium thiosulfate; protect from light by wrapping with opaque material such as aluminum foil

Nitroglycerin

Vasodilation by direct smooth muscle relaxation, predominantly venous Used in preload and/or afterload reduction (cardiogenic shock) Dose-dependent effect Arterial dilation only if infusion > 1 mcg/kg/min Side effects: ↑ or ↓ BP; ↑ or ↓ HR; palpitations; weakness; apprehension; flushing; dizziness; syncope; headache Nursing implications: monitor HR, BP, and urine output; monitor RAP, PAP, PAOP, SVR, CO, and CI if pulmonary artery catheter in place; use cautiously in cases of hypotension; administer in glass bottle with non-polyvinyl chloride tubing

Upon calling the health care provider regarding a client with "heartburn," diaphoresis, and irregular pulse, the nurse receives stat orders for the following: electrocardiogram, cardiac panel, morphine 2 mg IV push, nitroglycerin 0.4 mg sublingual, and aspirin 325 mg p.o. chew and swallow. Which tasks should the nurse delegate? Select all that apply. 1. Administration of medications 2. Reassessment of the client's condition 3. Venipuncture for the cardiac panel 4. Electrocardiogram 5. Oxygen saturation

Venipuncture for cardiac panel Electrocardiogram Oxygen saturation The nurse should delegate the venipuncture, electrocardiogram, and oxygen saturation to nursing unit staff or ancillary personnel. The nurse caring for the client should administer the medications and continue to assess the client. The nurse assigned to the client has a baseline of the client's condition, and can attest to changes in status

Those at risk for the development of shock include

Very young and very old clients Post MI clients Clients with severe dysrhythmia Clients with adrenocortical dysfunction Persons with a history of recent hemorrhage or blood loss Clients with burns Clients with massive or overwhelming infection

Cardiac output (CO)

Volume of blood ejected by the left ventricle per unit of time Stroke volume (amount of blood ejected per beat) x heart rate (normal 4-6 L/min)

Safety alert: complications of fluid resuscitation

Warm crystalloid and colloid solutions during massive fluid resuscitation to prevent hypothermia When giving large volumes of packed RBCs, remember that they do not contain clotting factors Replace clotting factors based on the clinical situation and laboratory studies

HESI hint

Workplace violence, substance abuse, bullying, social media, and inappropriate nurse-client relationships are areas of concern that nurse managers must provide systems in place to educate staff for heightened awareness of common behaviors associated with the items mentioned, as well as providing mechanisms for reporting any of these items

The delivery of care system on a medical floor is team nursing. On wing A, there is a registered nurse (RN), licensed practical/vocational nurse (LPN/LVN), and an unlicensed assistant person (UAP) to care for eight clients. Which tasks would be best delegated to the LPN?

Wound care and oral medications for all clients

The oncoming day shift nurse has received the shift report from the night nurse. The day shift nurse has done a quick check on all of the clients and has determined that all are stable and not in acute distress. Prioritize the order in which the oncoming nurse will care for the following clients, 1 being the first and 5 being the last

Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. Today the chest tube will be removed and the PCA pump will be discontinued. Middle-aged woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. Older man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. Older woman with advanced Alzheimer disease who requires total care for all ADLs. She struggles during any type of nursing care, and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility.