Patients with shock

In conducting health screenings, the nurse recognizes that which client is at greatest risk for shock secondary to trauma? a. 15-year-old high school basketball player b. 24-year-old computer specialist c. 48-year-old truck driver d. 62-year-old business executive

B Hypovolemic shock from trauma is more common in young adults. Other types of shock are more common among older adults.

A client admitted to the inpatient unit has been ordered to receive packed red blood cells to correct a moderate surgical blood loss. The client asks how this treatment will assist in his recovery. Which would be the nurse's best response? a. "It will help restore adequate electrolyte balance." b. "Surgical procedures often require blood replacement." c. "It will improve the ability of your blood to carry oxygen." d. "It will help to restore the oncotic pressure in your blood cells."

C Packed red blood cells are considered colloid fluids. They are most often used to restore red blood cell loss, thereby increasing the oxygen-carrying capacity of the blood without adding excess fluid volume.

The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication does the nurse expect to be prescribed? a. Heparin sodium b. Vitamin K c. Corticosteroids d. Hetastarch (Hespan)

A During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors. The other medications would not be prescribed during the hyperdynamic phase of septic shock.

The emergency department nurse assesses for which clinical manifestation in the client suspected to be in the nonprogressive stage of shock? a. Decreased heart rate and decreased urinary output b. Increased heart rate and decreased urinary output c. Increased pulse pressure and increased heart rate d. Decreased pulse pressure and decreased heart rate

B In the nonprogressive stage of shock, both kidney and cardiovascular compensations, in addition to chemical compensatory mechanisms, are needed. These result in an increase in heart rate and decrease in urinary output to maintain MAP (mean arterial pressure) and volume in the central blood vessels.

Which therapy will the nurse administer to the client in the late phase of septic shock? a. Anticoagulation therapy b. Clotting factors, platelets, and plasma c. Corticosteroids d. Protamine sulfate

B Therapy during the second (late) phase of septic shock is aimed at increasing the blood's ability to clot. This consists of administering clotting factors, plasma, platelets, and other blood products.

The nurse monitors the client with which disorder as being at a greater risk for an adverse event when receiving atropine sulfate? a. Bronchogenic carcinoma b. Gastroesophageal reflux c. Glaucoma d. Asthma

C Atropine sulfate should be given cautiously to clients with glaucoma because it might precipitate an episode of acute angle-closure glaucoma.

In monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride drip, the nurse recognizes which parameter as the desired response to this drug? a. Hypotension b. Tachycardia c. Increased cardiac output d. Decreased mean arterial pressure

C Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation.

For which manifestations will the nurse monitor when caring for the client with distributive shock resulting from an anaphylactic event? a. Increased heart rate and blood pressure b. Increased blood pressure and cardiac output c. Decreased blood pressure and respiratory rate d. Decreased blood pressure and edema

D Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak.

The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock? a. Severe head injury from a motor vehicle accident b. Diabetes insipidus from polycystic kidney disease c. Ischemic cardiomyopathy from severe coronary artery disease d. Vomiting of blood from a gastrointestinal ulcer

A Distributive shock is the type of shock that occurs when blood volume is not lost from the body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen. Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord injury, or head trauma. The other clients are at risk for hypovolemic and cardiogenic shock.

18. A client recovering from septic shock is preparing for discharge home. What priority information does the nurse include in the teaching plan for this client? a. "Clean your toothbrush with laundry bleach daily." b. "Bathe every other day with antimicrobial soap." c. "Wash your hands after changing pet litter boxes." d. "Use an electric razor when you shave your face."

A The client at risk for septic shock should be instructed to clean his or her toothbrush daily, either by running it through the dishwasher or by rinsing it in laundry bleach. Clients should be instructed to bathe daily and wash the armpits, the groin, and the rectal area. The client should refrain from cleaning pet litter boxes. Clients recovering from septic shock are not at higher risk for bleeding disorders.

The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what is the priority intervention for this client? a. Administer an aminoglycoside. b. Initiate a dopamine hydrochloride (Intropin) drip. c. Administer crystalloid fluids. d. Initiate an intravenous heparin drip.

C IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids. Aminoglycosides and heparin are given to clients with septic shock.

A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the client's systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first? a. Insert a Foley catheter to monitor urine output closely. b. Ask the client's family to come to the hospital because death is near. c. Initiate the prescribed dobutamine (Dobutrex) intravenous drip. d. Obtain blood cultures before administering the next dose of antibiotics.

C The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client's pulse pressure is decreasing rapidly. The family should be updated appropriately.

For which client should the nurse remain alert for the possible development of septic shock? a. 25-year-old man with irritable bowel syndrome b. 52-year-old man taking beta blockers for hypertension c. 37-year-old woman who is 20% above ideal body weight d. 68-year-old woman with cancer being treated with chemotherapy

D Certain conditions or treatments that can cause immunosuppression, such as having cancer and being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a person to septic shock.

A client admitted with a gastrointestinal ulcer is NPO and has a nasogastric tube connected to low suction. The nurse monitors the client for which type of shock? a. Distributive shock b. Obstructive shock c. Cardiogenic shock d. Hypovolemic shock

D This client is at risk for hypovolemic shock caused by bleeding from gastrointestinal ulcers, leading to fluid volume loss, and from nasogastric suction, which can compound the situation if the client is not sufficiently hydrated with IV fluids.

In monitoring a client receiving a dopamine hydrochloride drip for the treatment of shock, the nurse correlates which symptom as an indication of a possible overdose of this medication? a. Pallor b. Hypertension c. Palmar erythema d. Increased pulse deficit

B An overdose of dopamine hydrochloride is manifested by hypertension.

The nurse is assessing a client who is in early stages of hypovolemic shock. Which manifestations does the nurse expect? (Select all that apply.) a. Elevated heart rate b. Elevated diastolic blood pressure c. Decreased body temperature d. Elevated respiratory rate e. Decreased pulse rate

A B D Heart and respiratory rates increased from the client's baseline level and a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock.

While assessing the client at risk for shock, a nurse finds the client's systolic blood pressure to be 20 mm Hg lower than baseline. Which is the nurse's priority intervention? a. Increasing the IV rate b. Administering oxygen c. Notifying the physician d. Documenting the finding

B Administration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia

The nurse is providing health education to a client on immunosuppressant therapy. Which instructions does the nurse include in this client's teaching? (Select all that apply.) a. "Wear a facemask at all times." b. "Take your temperature once a day." c. "Drink only bottled water." d. "Avoid any contact with pets."

B E F Daily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune compromised client. Clients at increased risk because of immune suppression need to wear a facemask when in large crowds or around ill people. Water need not be bottled but should not be used if it has been standing for longer than 15 minutes. This population is not restricted from pets but is only advised not to change pet litter boxes.

The nurse is providing community education for clients at risk for dehydration. One client states, "We are not at risk because we live in a hot and dry climate." What is the nurse's best response? a. "You are still at risk but not as high a risk as those who live in hot and humid climates." b. "Any type of heat can cause peripheral vasoconstriction, which causes the body to lose water." c. "In a hot and dry environment, the body can lose an increased amount of water without your knowledge." d. "Even though you are not at risk, you should drink adequate fluids when you exercise."

C Teach everyone to prevent dehydration by having adequate fluid intake during exercise or when in a hot and dry environment. Insensitive water loss increases in this type of environment. Heat causes vasodilation as well, also contributing to water loss. The other statements are not accurate.

A client brought to the emergency room after a motor vehicle accident is suspected of having internal bleeding. Which initial clinical manifestation of hypovolemic shock would the nurse expect to find in this client? a. Increased respiratory rate b. Decreased urinary output c. Increased heart rate d. Cool pale skin

C The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress

The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock? a. "Is your blood pressure higher than usual?" b. "Are you having pain in your throat?" c. "Have you been vomiting?" d. "Are you usually this swollen?"

D Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.

The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client's shock is caused by sepsis? a. Hypotension b. Pale clammy skin c. Anxiety and confusion d. Oozing of blood at the IV site

D The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock

On discharge after undergoing an exploratory laparotomy, the nurse teaches the client to monitor for which sign of early shock? a. Decreased urine output b. Low body temperature c. Slow bounding pulse d. Constipation

A A decrease in urine output is a sensitive indicator of early shock. In severe shock, urine output is decreased (compared with fluid intake) or even absent.

The nurse is planning discharge education for a client who had an exploratory laparotomy. Which nursing statement is appropriate when teaching the client to monitor for early signs of shock? a. "Monitor how much urine you void and report a decrease in the amount." b. "Take your temperature daily and report any below-normal body temperatures." c. "Assess your radial pulse every day and report an irregular rhythm." d. "Monitor your bowel movements and report ongoing constipation or diarrhea."

A A decrease in urine output is a sensitive indicator of early shock. In severe shock, urine output is decreased (compared with fluid intake) or even absent. Alterations in temperature, irregular rhythms, and changes in bowel movements are not early signs of shock.

The client's urinary output is normal, whereas the respiratory rate and heart rate are slightly elevated from baseline. The nurse correlates these findings to which stage of shock? a. Early b. Compensatory c. Intermediate d. Refractory

A An increase in heart and respiratory rates (heart rate first) from the client's baseline or a slight increase in diastolic blood pressure may be the only objective manifestations of early shock.

The intensive care nurse is educating the spouse of a client who is being treated for shock. The spouse states, "The doctor said she has shock. What is that?" What is the nurse's best response? a. "Shock occurs when oxygen to the body's tissues and organs is impaired." b. "Shock is a serious condition, but it is not a life-threatening emergency." c. "Shock progresses slowly and can be stopped by the body's normal compensation." d. "Shock is a condition that affects only specific body organs like the kidneys."

A Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency. Shock represents the "whole-body response," affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal of the cause of shock, resulting in death.

A client in the hyperdynamic phase of septic shock has been admitted to the intensive care unit. For which complication will the nurse be alert for as shock progresses from the hyperdynamic to the hypodynamic phase? a. Acute respiratory distress syndrome b. Acute bowel obstruction c. Ventricular tachycardia d. Seizure activity

A As septic shock progresses to the hypodynamic phase, acute respiratory distress syndrome (ARDS), a potentially fatal complication, can develop. There will be decreased perfusion to the bowel, but a bowel obstruction is usually seen.

A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first? a. Obtain two sets of blood cultures. b. Administer the prescribed IV vancomycin (Vancocin). c. Obtain central venous pressure (CVP) measurements. d. Administer the prescribed IV norepinephrine (Levophed).

A Blood cultures should be obtained before IV antibiotics are started. If hypotension occurs, fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if hypotension persists.

A client admitted with septic shock develops tachycardia and an increase of 20 mm Hg in systolic blood pressure. Which pathophysiologic factors of hyperdynamic shock are responsible for these clinical manifestations? a. Inflammatory reaction of circulating endotoxins b. Vasoconstriction resulting in tissue hypoxia c. Reductions in hematocrit and hemoglobin d. Platelet aggregation

A Circulating endotoxins interact with white blood cells and blood vessel walls to trigger inflammatory reactions. Some endotoxins exert a direct effect on the heart, causing an initial increase in cardiac output and resulting in tachycardia, with normal to elevated systolic blood pressure. In hyperdynamic shock, vasodilation is present. Reductions in hematocrit and hemoglobin levels are seen late in septic shock accompanying hemorrhage. Platelet aggregation can cause microthrombus formation, leading to disseminated intravascular coagulation (DIC).

In caring for the client who has suffered a myocardial infarction, the nurse correlates which hemodynamic parameters with cardiogenic shock? a. Decreased cardiac output and decreased MAP b. Increased cardiac output and increased afterload c. Increased cardiac output and increased MAP d. Decreased cardiac output and increased MAP

A Myocardial infarction (MI) is a major cause of direct pump failure. With MI, cardiac output and MAP are decreased and afterload is increased.

The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question? a. Enoxaparin (Lovenox) 40 mg subcutaneous twice daily b. Transfusion of 2 units of fresh frozen plasma c. Regular insulin intravenous drip per protocol d. Cefazolin (Ancef) 1 g IV every 6 hours

A Therapy during the second (late) phase of septic shock is aimed at enhancing the blood's ability to clot. Enoxaparin would increase the client's risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client's blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.

A client who has a local infection of the right forearm is being discharged. The nurse teaches the client to seek immediate medical attention if which complication occurs? a. Dizziness on changing position b. Increased urine output c. Warmth and redness at site d. Low-grade temperature

A When a local infection becomes systemic, the client develops a high-grade temperature, decreased urine output, and increased respiratory rate. Because of tachycardia and low blood pressure, the client may exhibit orthostatic hypotension. This is a subtle sign of systemic infection that requires further evaluation by the health care provider. The other signs are not manifestations of complications. Warmth and redness are expected with local infection.

The nurse correlates which clinical manifestations with the early stages of hypovolemic shock? (Select all that apply.) a. Elevated heart rate b. Elevated systolic blood pressure c. Elevated diastolic blood pressure d. Decreased respiratory rate e. Decreased pulse rate f. Decreased body temperature

A C Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock.

A client has septic shock. Which hemodynamic parameters does the nurse correlate with this type of shock? (Select all that apply.) a. Decreased cardiac output b. Increased cardiac output c. Increased blood glucose d. Decreased blood glucose e. Increased serum lactate f. Decreased serum lactate

A C E Septic shock manifests with decreased cardiac output, increased blood glucose, and increased serum lactate. The other parameters do not correlate with septic shock.

The nurse includes which statements in the teaching for a client at risk for sepsis secondary to suppressed immune response? (Select all that apply.) a. "Wear a face mask at all times." b. "Take your temperature once a day." c. "Drink only bottled water." d. "Avoid any contact with pets." e. "Wash dishes with hot sudsy water." f. "Rinse your toothbrush in liquid laundry bleach."

B E F Daily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immunocompromised client. Clients at increased risk because of immunosuppression need to wear a face mask when in large crowds or around ill people. Water need not be bottled, but should not be used if it has been standing for longer than 15 minutes. This population is not restricted from pets, but only advised not to change pet litter boxes.

The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock? a. 15-year-old adolescent who plays high school basketball b. 24-year-old computer specialist who has bulimia c. 48-year-old truck driver who has a 40-pack-year history of smoking d. 62-year-old business executive who travels frequently

B Hypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting.

A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer? a. Normal saline b. Ringer's lactate c. 5% dextrose in water d. 5% dextrose in 0.45% normal saline

B Ringer's lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as a buffer in the presence of acidosis. The other solutions do not contain any substance that would buffer or correct the client's acidosis

In preparing a teaching plan, the nurse describes which environment as placing people at greatest risk for dehydration? a. Hot and humid b. Hot and dry c. Cold and humid d. Cold and dry

B Teach everyone to prevent dehydration by having an adequate fluid intake during exercise or when in a hot and dry environment. Insensitive water loss increases in this type of environment. The heat causes vasodilation as well, also contributing to water loss.

The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. Which nursing intervention is a priority when administering this medication? a. Ask if the client has chest pain every 30 minutes. b. Assess the client's blood pressure every 15 minutes. c. Monitor the client's urinary output every hour. d. Observe the client's extremities every 4 hours.

B The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and can increase shock. The nurse should monitor the client's pain, urinary output, and extremities, but these assessments do not directly relate to the nitroprusside infusion.

3. The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates that the client is at risk for acidosis? a. Decreased serum creatinine b. Increased serum lactic acid c. Increased urine specific gravity d. Decreased partial pressure of arterial carbon dioxide

B The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus some cells are metabolizing anaerobically. Such metabolism increases the production of lactic acid, resulting in an increase in hydrogen ion production and acidosis. Other laboratory values associated with acidosis include increased creatinine (impaired renal function) and increased partial pressure of arterial carbon dioxide. Urine specific gravity is not associated with acidosis

A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock? a. "Are you more thirsty than normal?" b. "When was the last time you urinated?" c. "What is your normal heart rate?" d. "Is your skin usually cool and pale?"

C The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress. The other questions would not identify early stages of shock.

A nurse notes that the cardiac output, systolic blood pressure, and pulse pressure are beginning to decrease rapidly in a client being treated for septic shock. Which conclusion can the nurse draw from these changes? a. Respiratory acidosis will follow quickly. b. Compensatory mechanisms are being activated. c. The client is in the hypodynamic phase of septic shock. d. The therapy for septic shock is beginning to demonstrate effectiveness.

C The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure

The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress. Which nursing intervention is most appropriate during this stage of sepsis? a. Check blood glucose levels every 4 hours. b. Monitor intake and urinary output twice each shift. c. Decrease ventilator rate and tidal volume. d. Administer prescribed low-dose corticosteroids.

D During severe sepsis, interventions should focus on decreasing hypoxia, maintaining acid-base balance, keeping blood glucose levels as normal as possible, maintaining organ perfusion, minimizing adrenal insufficiency, and decreasing microemboli. Treatment should include administration of low-dose corticosteroids, insulin drip with blood glucose checks every 1 to 2 hours, hourly intake and output monitoring, and an increase in ventilator rate and tidal volume.

The nurse recognizes which client as being at highest risk for septic shock? a. 12-year-old with open fracture of the left femur and two peripheral IVs b. 35-year-old with HIV receiving enteral feedings via a percutaneous endoscopic gastrostomy (PEG) tube c. 65-year-old with pneumonia receiving IV fluids and broad-spectrum oral antibiotics d. 82-year-old with leukemia receiving broad-spectrum IV antibiotics via a triple-lumen central line

D Risk factors for sepsis and septic shock in the 82-year-old client include age older than 80, immunosuppression, and invasive lines, particularly triple-lumen central line catheters. This client has three risk factors. The 12 year-old client has two risk factors, open fracture and peripheral IVs. The 35-year-old client with HIV has one risk factor, immunosuppression. The 65-year-old client has one risk factor, IV access.