Module 4 Chapter 37 Care of Patients with Shock
Where are the baroreceptors that are responsible for detection of pressure changes within the arterial system located? 1 Aortic arch 2 Radial sinus 3 Brachial arch 4 Femoral sinus
1 Aortic arch The baroreceptors responsible for detecting pressure changes in the arterial system are located in aortic arch and carotid sinus. There are no baroreceptors located in radial sinus, brachial arch, and femoral sinus.
The nurse is administering continuous intravenous infusion of norepinephrine (Levophed) to a client in shock. Which finding causes the nurse to decrease the rate of infusion? 1 Blood pressure 170/96 mm Hg 2 Respiratory rate 22 breaths/min 3 Urine output of 70 mL/hr 4 Heart rate 98 beats/min
1 Blood pressure 170/96 mm Hg Signs of excess vasoconstricting drugs include headache, hypertension, and decreased renal perfusion manifested by oliguria. While vasoconstricting medications and the shock state may cause tachycardia (heart rate greater than 100 beats/min), this client's heart rate is within normal range. Vasoconstricting drugs do not affect the respiratory rate; shock itself causes an increased respiratory rate in an effort to deliver more oxygen to the tissues. Study Tip: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.
A client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? 1 Broad-spectrum antibiotics 2 Blood transfusion 3 Cooling baths 4 Nothing by mouth (NPO) status
1 Broad-spectrum antibiotics Broad-spectrum antibiotics must be initiated within 1 hour of establishing diagnosis. A blood transfusion is indicated for low red blood cell (RBC) count or low hemoglobin and hematocrit; transfusion is not part of the sepsis resuscitation bundle. Cooling baths are not indicated because the client is hypothermic, nor is this part of the sepsis resuscitation bundle. NPO status is not indicated for this client, nor is it part of the sepsis resuscitation bundle. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.
The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22/min. What does the supervising nurse do? 1 Compare these vital signs with the last several readings. 2 Request the surgeon see the client. 3 Increase the rate of intravenous fluids. 4 Reassess vital signs using different equipment.
1 Compare these vital signs with the last several readings. Vital sign trends must be taken into consideration; a BP of 90/60 may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment should be used when vital signs are taken postoperatively.
A client reports vomiting and diarrhea for 24 hours and feeling lightheaded and weak. The client has not been able to keep fluids down for the past 12 hours, and the client's skin is cool and moist to touch. Which provider order for this client does the nurse clarify? 1 Encourage fluids by mouth. 2 Oxygen by nasal cannula to maintain oxygen saturation >95%. 3 Call for decrease in mean arterial pressure >10 mm Hg. 4 Call for urine output <30 mL/hour.
1 Encourage fluids by mouth. The client is most likely hypovolemic from 24 hours of vomiting and diarrhea. The client needs IV fluids to replace intravascular fluid volume. Taking fluids by mouth will not be effective in quickly restoring the client's blood volume while nausea and diarrhea persist. The other responses are appropriate orders. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.
The client with which problem is at highest risk for hypovolemic shock? 1 GI ulcer 2 Kidney failure 3 Arthritis and daily acetaminophen use 4 Kidney stone
1 GI ulcer GI ulcers may hemorrhage, causing massive gastrointestinal (GI) bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and ibuprofen, not acetaminophen, predispose the client to GI bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss and hypovolemia. Test-Taking Tip: Notice how the subjects of the questions are related and, through that relationship, the answers to some of the questions may be provided within other questions of the test.
A client has developed hypovolemic shock related to profound ascites and fluid shift. Which laboratory value does the nurse expect to see? 1 Hematocrit 54% 2 Paco2 45 mm Hg 3 Potassium 4.4 mEq/L 4 Lactic acid 2.2 mmol/L
1 Hematocrit 54% Shock caused by dehydration or fluid shifts results in increased hemoglobin and hematocrit levels due to hemoconcentration. The Paco2, potassium, and lactic acid values given are within normal limits; they would be increased in the client who is in a shock state. Study Tip: When forming a study group, carefully select members for your group. Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms.
The client with which lab result is at risk for hemorrhagic shock? 1 International Normalized Ratio (INR) 7.9 2 Partial thromboplastin time (PTT) 12.5 seconds 3 Platelets 170,000/mm3 4 Hemoglobin 8.2 g/dL
1 International Normalized Ratio (INR) 7.9 Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
The expected outcome of the sepsis resuscitation bundle for a client with septic shock has been met when which parameter is present? 1 Lactate level of <4 mmol/L 2 Mean arterial blood pressure of 55 mm Hg 3 Negative blood cultures after 24 hr 4 Presence of anuria for less than 24 hr
1 Lactate level of <4 mmol/L Effective fluid resuscitation will restore tissue perfusion, correcting lactic acidosis and meeting the goal of a lactate level of 4 mmol/L. Mean arterial pressure in septic shock should be maintained at 65 mm Hg for adequate tissue perfusion. Blood cultures may take 3 days to grow; appropriate treatment is initiated prior to culture results. The result of treatment of sepsis is to maintain a urine output of at least 20 mL/hr. Study Tip: Focus your study time on the common health problems that nurses most frequently encounter.
A client is admitted with new-onset hypotension, tachycardia, tachypnea, and elevated white blood cell count, but blood cultures are negative. The client is becoming increasingly confused. What is the nurse's best action? 1 Notify the Rapid Response Team. 2 Establish an IV for possible fluid administration. 3 Activate the bed alarm. 4 Reorient the client frequently.
1 Notify the Rapid Response Team. Systemic inflammatory response syndrome (SIRS) manifests similarly to sepsis in which the client is underperfused, but an infectious cause may not be present. Worsening confusion suggests the client is progressing in shock state and a Rapid Response Team should be called to assess and treat the client's hypoperfusion. Establishing an IV for fluid administration is an appropriate action, but not before calling the Rapid Response Team. Reorienting the client and activating the bed alarm will not address the underlying cause of the confusion. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.
A client recovering from an open reduction of the femur suddenly feels lightheaded, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? 1 Temperature 2 Pulse 3 Respiration 4 Blood pressure
1 Temperature A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.
Which vital sign change in a client with hypovolemic shock indicates to the nurse that the fluid resuscitation therapy is effective? 1 Urine output increase from 5 to 35 mL/hr 2 Heart rate increase from 62 to 76 beats/min 3 Respiratory rate increase from 22 to 26 breaths/min 4 Core body temperature decrease from 98.8° F (37.1° C) to 98.2° F (36.8° C)
1 Urine output increase from 5 to 35 mL/hr During shock, the kidneys and baroreceptors sense an ongoing decrease in mean arterial pressure and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase. An increase in respiratory rate, increase in heart rate, and a decrease in core body temperature are not expected findings of successful fluid resuscitation. Study Tip: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.
A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. 1 Ask family members to stay with the client. 2 Call the health care provider. 3 Increase IV and oxygen rates. 4 Remain with the client. 5 Reassure the client that everything is being done for him or her.
1 Ask family members to stay with the client. 4 Remain with the client. 5 Reassure the client that everything is being done for him or her. Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen may be needed, but these actions do not support the client's psychosocial integrity.
Which clients are at immediate risk for hypovolemic shock? Select all that apply. 1 Unrestrained in motor vehicle accident 2 Construction worker 3 Athlete 4 Surgical intensive care client 5 85-year-old with gastrointestinal virus
1 Unrestrained in motor vehicle accident 4 Surgical intensive care client 5 85-year-old with gastrointestinal virus
A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? 1 Hourly urine output 10-12 mL/hr 2 Blood pressure 90/60 and mean arterial pressure (MAP) 70 3 Blood glucose 245 4 Serum creatinine 3.6 mg/dL
2 Blood pressure 90/60 and mean arterial pressure (MAP) 70 Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and is a negative consequence of shock, not a positive response. Although a blood glucose of 245 is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.
A client admitted with a bleeding duodenal ulcer is NPO and has a nasogastric tube in place connected to low continuous suction. What assessment finding does the nurse report to the provider as a possible indicator of nonprogressive stage of shock? 1 Serum potassium level of 4.7 mEq/L 2 Decrease in mean arterial pressure (MAP) from 76 mm Hg to 62 mm Hg 3 Urine output of 30 mL/hour 4 Increased confusion
2 Decrease in mean arterial pressure (MAP) from 76 mm Hg to 62 mm Hg When shock progresses from the initial stage to the nonprogressive stage, symptoms are subtle but present. Once the client enters the progressive and refractory stage of shock, manifestations are more obvious and may not be responsive to therapy. Recognizing early manifestations of shock are important to client outcomes. The nonprogressive stage of shock is present when the MAP decreases by 10-15 mm Hg from baseline, urine output decreases, and heart rate and respiratory rate increase. Confusion and moderate hyperkalemia is observed in the progressive stage of shock. The client's urine output is still within normal limits as may be seen in the initial stage of shock, but urine output will continue to decrease as the shock stages progress. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.
Which laboratory result is seen in late sepsis? 1 Decreased serum lactate 2 Decreased segmented neutrophil count 3 Increased numbers of monocytes 4 Increased platelet count
2 Decreased segmented neutrophil count A decreased segmented neutrophil count is indicative of late sepsis. Serum lactate is increased in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis; late in sepsis, platelets may decrease due to consumptive coagulopathy. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.
Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? 1 Localized erythema and edema 2 Low-grade fever and mild hypotension 3 Low oxygen saturation rate and decreased cognition 4 Reduced urinary output and an increased respiratory rate
2 Low-grade fever and mild hypotension Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and an increased respiratory rate indicate severe sepsis. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option.
How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? 1 Urine output 20-30 mL/hr for the last 4 hours 2 Mean arterial pressure (MAP) 70 mm Hg 3 Albumin level 3.5 4 Hemoglobin 7.6 g/dL
2 Mean arterial pressure (MAP) 70 mm Hg Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, which is a desired outcome in shock. Urine output should be 0.5 mL/kg/hr or greater than 30 mL/hr. Albumin levels reflect nutritional status, which may be poor in shock states due to an increased need for calories. Plasmanate expands blood volume by exerting increasing colloid osmotic pressure in the bloodstream, pulling fluid into the vascular space; this does not improve an abnormal hemoglobin. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.
A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? 1 Obtain vital signs every 15 minutes. 2 Measure hourly urine output. 3 Check oxygen saturation. 4 Assess level of alertness.
2 Measure hourly urine output. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed. Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.
A client is at risk for hypovolemic shock. The nurse suspects the nonprogressive (compensatory) phase of shock is occurring when which factor is present? 1 Rise in systolic blood pressure 2 Narrowing pulse pressure 3 Slow, bounding pulse 4 +3 pedal pulse
2 Narrowing pulse pressure The nonprogressive (compensatory) stage of shock causes tachycardia, decreased systolic blood pressure, and increased diastolic blood pressure, which narrows the pulse pressure (difference between the systolic and diastolic pressures) secondary to catecholamine release. Typically distal pulses are weak and thready as hypovolemic shock progresses. Study Tip: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation.
The client in shock has the following vital signs: T 99.8° F, P 132, R 32, and BP 80/58. Calculate the pulse pressure. Record as a whole number.
22 Pulse pressure is the difference between the systolic and diastolic pressures. 80 (systolic) - 58 (diastolic) = 22 (pulse pressure) Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.
Which of these individuals may be at highest risk for hypovolemic shock? 1 Client with acute kidney failure 2 Client with myocardial infarction 3 Client who overdosed on bumetamide (Bumex) 4 Client with benign prostatic hyperplasia (BPH)
3 Client who overdosed on bumetamide (Bumex) Hypovolemic shock results from decreased circulating blood volume; bumetamide, a potent loop diuretic, decreases blood volume. A myocardial infarction may lead to cardiogenic shock or heart failure, with resulting fluid volume excess rather than hypovolemia. Kidney failure results in increased blood volume (hypervolemia) as the failing kidney is unable to produce urine. BPH obstructs the outflow of urine into the bladder as prostatic tissue enlarges; blood volume is not reduced. Study Tip: Try to decrease your workload and maximize your time by handling items only once. Most of us spend a lot of time picking up things we put down rather than putting them away when we have them in hand. Going straight to the closet with your coat when you come in instead of throwing it on a chair saves you the time of hanging it up later. Discarding junk mail immediately and filing the rest of your bills and mail as they come in rather than creating an ever-growing stack saves time when you need to find something quickly. Filing all items requiring further attention in some fashion helps you remember to take care of things on time rather than being so engrossed in your schoolwork that you forget about them. Many nursing students have had their power or telephone service cut off because the bill simply was forgotten or buried in a pile of old mail.
A client in hypovolemic shock has been placed on an infusion of the vasopressor agent norepinephrine (Levophed). Which parameter indicates a desired client response to the therapy? 1 Heart rate change from 112 to 123 beats/min 2 Decreased peripheral pulses 3 Mean arterial pressure change from 66 to 78 mm Hg 4 Urine output remains at 30 mL/hour
3 Mean arterial pressure change from 66 to 78 mm Hg If fluid therapy is not effective in increasing blood pressure, vasoconstricting drugs may be added to increase tissue perfusion. When vasoactive agents are administered, the nurse monitors for effectiveness by evaluating improvements in cardiac output and mean arterial pressure. An increase, not decrease, in urine output is a desired response. An increased heart rate is expected due to sympathetic nervous system stimulation of norepinephrine. Decreased peripheral pulses may occur due to vasoconstrictor effects, but it is not a desired response. Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, "I know the material, and I'll do well on the test." Try it; many students have found that it works because it reduces "test anxiety."
The nurse in the postanesthesia care unit is caring for a postoperative client whose heart rate suddenly increases to 122 beats/min and the blood pressure drops to 84/48 mm Hg. Which position does the nurse use to improve the client's blood pressure and organ perfusion? 1 Sims' 2 Lithotomy 3 Modified Trendelenburg 4 Head of bed 30 degrees, legs flat
3 Modified Trendelenburg Maintaining the client flat with the feet elevated (modified Trendelenburg) improves venous return and perfusion to the brain. Sims' position refers to lying on the left side with the top leg flexed, typically used for enemas and GI procedures. The lithotomy position is used for gynecologic examination and procedures. The head of bed elevated at 30 degrees describes a semi-Fowler's position used to prevent aspiration. Study Tip: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment.
A client is scheduled for thoracotomy later today. Which entry noted on the medication reconciliation record poses a risk for perioperative hemorrhagic shock and causes the nurse to contact the provider immediately? 1 Captopril (Catapres) 2 Furosemide (Lasix) 3 Naproxen (Naprosyn) 4 Omeprazole (Prilosec)
3 Naproxen (Naprosyn) Naproxen is a nonsteroidal antiinflammatory agent that poses a risk for bleeding. Captopril (for hypertension), furosemide (for heart failure), or omeprazole (prevents gastroesophageal reflux disease and gastrointestinal bleeding from stomach ulcers) do not pose risks for bleeding. Anticoagulants, aspirin, and NSAIDs should be questioned. Study Tip: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.
What typical sign/symptom indicates the early stage of septic shock? 1 Pallor and cool skin 2 Blood pressure 84/50 mm Hg 3 Tachypnea and tachycardia 4 Respiratory acidosis
3 Tachypnea and tachycardia Signs of systemic inflammatory response syndrome, which precede sepsis, include rapid respiratory rate, leukocytosis, and tachycardia. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis occurs early in shock because of an increased respiratory rate.
A client admitted with pneumonia and possible sepsis has a blood pressure of 90/46 mm Hg, heart rate of 128 beats/min, respiratory rate of 28/min, temperature of 38.5° C, no urine output for 4 hours, and central venous pressure of 2 mm Hg. The client arouses to name but is not oriented. Which order does the nurse implement first? 1 Obtain blood cultures. 2 Insert an indwelling urinary catheter. 3 Apply a cooling blanket. 4 Administer 500 mL intravenous colloid bolus over 30 minutes.
4 Administer 500 mL intravenous colloid bolus over 30 minutes. A resuscitation bundle is used for the treatment of sepsis. While several interventions are part of a bundle, the nurse prioritizes the interventions based on the assessment of the client. Establishing perfusion is a priority with this client, thus starting the IV fluid bolus should be the first priority in care. Obtaining blood cultures, especially prior to administering antibiotics, is also important along with placing an indwelling urinary catheter to monitor the client's response to fluid therapy. A cooling blanket is not part of the bundle and may not be an appropriate intervention. Test-Taking Tip: Avoid choosing answers that use words such as always, never, must, all, and none. If you are confused about the question, read the choices, label them true or false, and choose the answer that is the odd one out (i.e., the one false one or the one true one). When a question is framed in the negative, such as "When assessing for pain, you should not," the false option is the correct choice.
A client with hypovolemic shock has these vital signs: temperature 97.9° F; pulse 122 beats/min; blood pressure 86/48 mm Hg; respirations 24/min; urine output 20 mL for last 2 hours; skin cool and clammy. Which medication order for this client does the nurse question? 1 Dopamine (Intropin) 12 mcg/kg/min 2 Dobutamine (Dobutrex) 5 mcg/kg/min 3 Plasmanate 1 unit 4 Bumetamide (Bumex) 1 mg IV
4 Bumetamide (Bumex) 1 mg IV A diuretic like bumetamide will decrease blood volume in a client who is already hypovolemic; this order should be questioned because this is not an appropriate action to expand the client's blood volume. The other orders are appropriate for improving blood pressure in shock, and do not need to be questioned. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.
When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? 1 Obtain IV access and hang prescribed fluid infusions. 2 Apply the automatic blood pressure cuff. 3 Assess level of consciousness and pupil reaction to light. 4 Check the airway and respiratory status.
4 Check the airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status. Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for action.
A client in the progressive or intermediate stage of hypovolemic shock will exhibit which manifestation? 1 Polyuria 2 Metabolic alkalosis 3 Moist, warm skin 4 Feeling of impending doom
4 Feeling of impending doom As shock progresses, tissue perfusion to the brain continues to be reduced, causing a sense of anxiety or that "something bad" is about to happen. Oliguria or anuria occurs in the nonprogressive stage rather than polyuria. A lack of perfusion to the skin results in cool, moist skin rather than warm skin. Due to decreased tissue perfusion, buildup of lactic or metabolic acid occurs; the arterial blood gases reflect metabolic acidosis at this time. Study Tip: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.
The nurse is preparing to administer a transfusion of packed red blood cells to a client with hemorrhagic shock. Which action is essential before initiating the transfusion? 1 Check the volume of blood in the bag. 2 Monitor the client for dark-colored urine. 3 Measure the client's blood pressure. 4 Initiate 0.9% saline solution infusion.
4 Initiate 0.9% saline solution infusion. Isotonic solutions such as Ringer's lactate or normal saline may be used as volume expanders in hypovolemic shock. Red blood cells must be given with 0.9% saline to prevent clotting during infusion. While the volume of the blood in the bag is approximately 250 mL, it may vary; however, this is not essential to validate before initiating the transfusion. The nurse monitors for dark urine when an ABO transfusion reaction is suspected. Vital signs, especially a baseline temperature, are indicated prior to transfusion; a low blood pressure during shock states is expected. Study Tip: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.
In acute shock, which organ has the capacity to tolerate hypoxia and anoxia for 1 hour without sustaining permanent injury? 1 Liver 2 Heart 3 Brain 4 Kidney
4 Kidney The kidney can tolerate hypoxia and anoxia for approximately 1hour without any permanent damage. The liver, heart, and brain use more oxygen and do not have the ability to function normally without adequate oxygen for more than a few minutes.
Which type of shock is often caused by pulmonary embolism? 1 Hypovolemic shock 2 Cardiogenic shock 3 Distributive shock 4 Obstructive shock
4 Obstructive shock Pulmonary embolism can cause obstructive shock by blocking the circulation of blood in the lungs and heart, thus reducing overall cardiac output. Total body fluid is not affected, but central volume is decreased. Hypovolemic shock is characterized by a marked reduction in total blood volume. Cardiogenic shock is caused by failure of the heart to pump blood. Distributive shock is caused by a shift of blood from the vascular spaces to interstitial spaces. Pulmonary embolism does not directly affect total blood volume, myocardial function, or fluid levels in vascular and interstitial spaces.
Which vasodilator drug is often helpful in managing hypovolemic shock? 1 Milrinone (Primacor) 2 Dobutamine (Dobutrex) 3 Phenylephrine HCl 4 Sodium nitroprusside (Nitropress)
4 Sodium nitroprusside (Nitropress) Sodium nitroprusside dilates the coronary arteries, enhancing myocardial perfusion and improving hypovolemic shock. Milrinone and dobutamine are both inotropic agents that act by increasing the force of heart muscle contractions. Phenylephrine is vasoconstrictor, not a vasodilator.
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? 1 Hypotension 2 Bradypnea 3 Heart blocks 4 Tachycardia
4 Tachycardia Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.
Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? 1 The LPN/LVN who has 20 years of experience 2 The new RN who recently finished orienting and is working independently with moderately complex clients 3 The RN who will also be caring for a client who had coronary artery bypass grafting (CABG) 12 hours ago 4 The RN with 2 years of experience in intensive care
4 The RN with 2 years of experience in intensive care The RN with current intensive care experience who is not caring for a postoperative client would be an appropriate assignment. Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. The client who is experiencing septic shock is too complex for the new RN. Although the RN is experienced, this assignment will put the post-CABG client at risk for MRSA infection. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.
Why are the clinical signs and symptoms of most types of shock the same, regardless of what condition caused the shock to occur? 1 An increase in heart rate is always the first physiologic adjustment the body makes to all stress states. 2 Because blood loss occurs with all types of shock, the most common first clinical symptom is hypotension. 3 Every type of shock interferes with cellular oxygenation in the same sequence. 4 The sympathetic nervous system is triggered by any type of shock and initiates the stress response.
4 The sympathetic nervous system is triggered by any type of shock and initiates the stress response Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems. Study Tip: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.
