Quiz 5: Shock

A patient is showing early clinical manifestations of hypovolemic shock. The healthcare provider orders an arterial blood gas (ABG). Which ABG values does the nurse expect to see in hypovolemic shock? A. Increased pH with decreased PaO2 and increased PaCO2 B. Decreased pH with decreased PaO2 and increased PaCO2 C. Normal pH with decreased PaO2 and normal PaCO2 D. Normal pH with decreased PaO2 and decreased PaCO2

B. Decreased pH with decreased PaO2 and increased PaCO2

Based on analysis of ABG values (PaCO2 62 mm Hg, PaO2 50 mm Hg, HCO3 22 mEq/L, O2 82%, pH 7.23), which collaborative intervention will the nurse anticipate next? A. Sodium bicarbonate bolus IV B. Endotracheal intubation and mechanical ventilation C. Continuous monitoring of Ms. D's respiratory status D. Nebulized albuterol therapy

B. Endotracheal intubation and mechanical ventilation

A patient is in hypovolemic shock related to hemorrhage from a large gunshot wound. Which order must the nurse question? A. Establish a large-bore peripheral IV and give crystalloid bolus B. Give furosemide (Lasix) 20 mg slow IVP C. Insert a Foley catheter and monitor intake and output D. Give high-flow oxygen via mask at 10 L/min

B. Give furosemide (Lasix) 20 mg slow IVP

The nurse quickly reviews Ms. D's latest laboratory test results, which have just arrived on the unit: Hematocrit: 32% (0.32) Hemoglobin: 10.9 Platelet count: 96,000 WBC: 26,000 BUN: 56 Creatinine: 2.9 Glucose: 330 Potassium: 5.2 Sodium: 140 Which laboratory value requires the most immediate action by the nurse? A. Creatinine level B. Glucose level C. Potassium level D. Hemoglobin level

B. Glucose level

The nurse is preparing to transfer Ms. D to the intensive care unit (ICU). Using SBAR (situation, background, assessment, recommendation) format, in what order will the nurse communicate pertinent information about Ms. D to the ICU nurse? 1. "Current blood pressure is 92/42, pulse rate 112, and respirations 32. Capillary blood glucose is 167 mg/dL, and lactate level is 36.04. Blood and urine culture pending" 2. "The patient has diabetes and chronic atrial fibrillation. She has been experiencing nausea, abdominal pain, and back pain. Today she was noted to be increasingly lethargic" 3. "Ms. D will need a central line insertion for fluid and vasopressor management, along with titration of norepinephrine and normal saline to maintain mean arterial pressure at 65 mm Hg" 4. "Ms. D is ready to transfer to intensive care. She has septic shock and is receiving mechanical ventilation, norepinephrine drip, and normal saline infusion through a peripheral line"

4, 2, 1, 3

When the nurse is preparing to assist with endotracheal intubation of Ms. D, in which order will these actions be accomplished? 1. Use capnography to check for exhaled carbon dioxide 2. Secure the endotracheal tube in place 3. Preoxygenate with bag-valve mask device at 100% oxygen 4. Inflate the endotracheal tube cuff 5. Obtain all needed equipment and supplies 6. Insert the endotracheal tube orally through the vocal cords

5, 3, 6, 4, 1, 2

The cardiac monitor shows this rhythm (Afib). Routine treatment orders for dysrhythmias are in the emergency department protocols. Which action should the nurse take next? A. Continue to monitor cardiac rhythm B. Administer metoprolol 5 mg IV push C. Prepare to perform cardioversion at 50 J D. Administer amiodarone 150 mg IV push

A. Continue to monitor cardiac rhythm

Ms. D is transferred to the ICU, and a two-port central IV line is started at the subclavian site to infuse fluids and norepinephrine. The intensive care nurse is working with an experienced LPN/LVN in caring for Ms. D. Which nursing activities included in the care plan should be assigned to the LPN/LVN? SATA A. Documenting the hourly urinary output B. Monitoring the central line site for signs of infection C. Checking capillary blood glucose levels every 2 hours D. Completing a head-to-toe assessment every 4 hours E. Administering sliding-scale insulin lispro per protocol F. Infusing normal saline at 400 mL/hr

A. Documenting the hourly urinary output C. Checking capillary blood glucose levels every 2 hours E. Administering sliding-scale insulin lispro per protocol

The nurse identifies signs and symptoms of internal hemorrhage in a postoperative patient. What is included in the care of this patient for hypovolemic shock? SATA A. Elevate the feet with the head of flat or elevated at 30 degrees B. Monitor vital signs every 5 minutes until they are stable C. Administer clotting factors or plasma D. Provide oxygen therapy E. Ensure IV access F. Leave the patient and notify the Rapid Response Team

A. Elevate the feet with the head of flat or elevated at 30 degrees B. Monitor vital signs every 5 minutes until they are stable D. Provide oxygen therapy E. Ensure IV access

Which questions can help guide the nurse when evaluating the mental status of a patient at risk for shock? SATA A. Is it necessary to repeat questions to obtain a response? B. Can the patient answer "yes" or "no" questions? C. Does the response answer the question asked? D. Does the patient have difficulty making word choices? E. Is the patient irritated or upset by the questions? F. How long is the patient's attention span?

A. Is it necessary to repeat questions to obtain a response? C. Does the response answer the question asked? D. Does the patient have difficulty making word choices? E. Is the patient irritated or upset by the questions? F. How long is the patient's attention span?

Available staffing in the emergency department includes an experienced unlicensed assistive personnel (UAP). Which actions should the nurse delegate to the UAP? SATA A. Measuring vital signs every 15 minutes B. Attaching the patient to a cardiac monitor C. Documenting a head-to-toe assessment D. Checking orientation and alertness E. Inserting an IV line F. Monitoring urine output hourly

A. Measuring vital signs every 15 minutes B. Attaching the patient to a cardiac monitor F. Monitoring urine output hourly

The nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations are markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

Assessment findings of a patient with trauma injuries reveal cool and pale skin, reported thirst, urine output 100mL/8 hr, blood pressure 122/78 mm Hg, pulse 102 beats/min, and respirations 24/min with decreased breath sounds. The nurse recognizes that the patient is in which phase of shock? A. Nonprogressive B. Progressive C. Refractory D. Multiple organ dysfunction

A. Nonprogressive

What factor increases an older adult's risk for distributive (septic) shock? A. Reduced skin integrity B. Diuretic therapy C. Cardiomyopathy D. Musculoskeletal weakness

A. Reduced skin integrity

The home health nurse is visiting a frail older adult patient at risk for sepsis because of failure to thrive and immunosuppression. What does the nurse assess this patient for? SATA A. Signs of skin breakdown and presence of redness or swelling B. Cough or any other symptoms of a cold or the flu C. Appearance and odor of urine, and pain or burning during urination D. Patient's and family's understanding of isolation precautions E. Availability and type of facilities for handwashing F. General cleanliness of the patient's home

A. Signs of skin breakdown and presence of redness or swelling B. Cough or any other symptoms of a cold or the flu C. Appearance and odor of urine, and pain or burning during urination E. Availability and type of facilities for handwashing F. General cleanliness of the patient's home

A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? A. An irreversible phenomenon B. A failure of the circulatory pump C. Usually a fleeting reaction to tissue injury D. Generally caused by decreased blood volume

B. A failure of the circulatory pump

While being prepared for surgery for a ruptured spleen, a client complains of feeling light-headed. The client's color is pale and the pulse is rapid. What should the nurse conclude about the client's condition? A. Hyperventilating B. Going into shock C. Experiencing anxiety D. Developing an infection

B. Going into shock

A patient is brought to the emergency department (ED) with a gunshot wound. What are the early signs of hypovolemic shock the nurse should monitor? SATA A. Elevated serum potassium level B. Increase in heart rate C. Decrease in oxygen saturations D. Marked decrease in blood pressure E. Increase in respiratory rate F. Decreased MAP of 10-15 mm Hg

B. Increase in heart rate E. Increase in respiratory rate F. Decreased MAP of 10-15 mm Hg

A patient has a systemic infection with a fever, increased respiratory rate, and change in mental status. Which laboratory values does the nurse seek out that are considered "hallmarks" of sepsis? A. Increased white blood cell count and increased glucose level B. Increased serum lactate level and rising band neutrophils C. Increased oxygen saturation and decreased clotting times D. Decreased white blood count with increased hematocrit

B. Increased serum lactate level and rising band neutrophils

Which method of oxygen administration will be best to increase Ms. D's oxygen saturation? A. Nasal cannula B. Nonrebreather C. Venturi mask D. Simple face mask

B. Nonrebreather

Ms. D, a 54-year-old patient, is brought to the emergency department by her daughter because of weakness and a decreasing level of consciousness. The daughter says that Ms. D has been reporting nausea, with associated abdominal and back pain. Although usually Ms. D is very alert and oriented, today she has been increasingly lethargic. Her medical history includes hypertension, atrial fibrillation, and diabetes mellitus type 2. The initial vital signs are as follows: BP: 102/38 HR: 102 bpm O2 Sat: 76% RR: 30 breaths/min Temp: 102.4F Based on the initial history and assessment, which action prescribed by the healthcare provider (HCP) will the nurse implement first? A. Insert a foley catheter and monitor urine output hourly B. Start oxygen and maintain oxygen saturation at 90% or higher C. Place the patient on a cardiac monitor D. Check the blood glucose level

B. Start oxygen and maintain oxygen saturation at 90% or higher

A patient comes to the emergency department (ED) with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? A. Whole blood B. 0.5% dextrose in water C. 0.9% sodium chloride D. Plasma protein fractions

C. 0.9% sodium chloride

A patient at risk for hypovolemic shock has a central venous pressure (CVP) catheter in place. Which finding is a priority concern for the nurse? A. Heart rate is decreased from 120 to 110 per minute B. Central venous pressure is increased from 1 to 6 mm Hg C. Central venous pressure is decreased from 6 to 1 mm Hg D. Heart rate is increased from 100 to 110 per minute

C. Central venous pressure is decreased from 6 to 1 mm Hg

A patient receives dopamine 20 mcg/kg/min IV for the treatment of shock. What does the nurse assess for while administering this drug? A. Decreased urine output and decreased blood pressure B. Increased respiratory rate and increased urine output C. Chest pain and hypertension D. Bradycardia and headache

C. Chest pain and hypertension

After 2 hours, the values for vital signs are as follows: BP: 104/56 HR: 104 bpm O2 Sat: 92% Central Venous Pressure: 3 mm Hg RR: 26 breaths/min Temp: 101.6F Which information about Ms. D is most important for the nurse to communicate to the healthcare provider? A. Decreased blood pressure B. Ongoing atrial fibrillation C. Low central venous pressure D. Continued temperature elevation

C. Low central venous pressure

Which condition results in blood vessels that are normally partially constricted? A. Hypoxia B. Vasodilation C. Sympathetic tone D. Decreased mean arterial pressure

C. Sympathetic tone

The nurse is caring for a patient in septic shock with a serum glucose level of 280 mg/dL. What is the nurse's best interpretation of this finding? A. The patient is developing type 2 diabetes B. The patient is developing type 1 diabetes C. This finding is associated with a poor outcome D. This finding is unexpected in septic shock

C. This finding is associated with a poor outcome

Which of these actions prescribed by the HCP will be most important for the nurse to question? A. Increase oxygen flow rate B. Raise normal saline rate to 450 mL/hr C. Administer acetaminophen 650 mg rectally D. Increase norepinephrine infusion rate to 12 mcg/kg

D. Increase norepinephrine infusion rate to 12 mcg/kg

The nurse is evaluating the care and treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment? A. Blood pH of 7.28 B. Arterial PO2 of 65 mm Hg C. Distended neck veins D. Increased urinary output

D. Increased urinary output

A patient with head trauma was treated for a cerebral hematoma. After surgery, this patient is at risk for what type of shock? A. Obstructive B. Cardiogenic C. Chemical-induced distributive D. Neural-induced distributive

D. Neural-induced distributive

The nurse is caring for a postoperative patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock? A. Pulse pressure of 40 mm Hg B. A rapid, weak, thready pulse C. Warm, flushed skin D. Increased urinary output

B. A rapid, weak, thready pulse

Which statement about assessment of skin during shock is accurate? A. For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes B. For all patients in shock, the skin is expected to feel warm and dry to the touch C. For a lighter skinned patient, skin is usually a whitish blue color D. For a patient with dark skin, color will be bluish gray

A. For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes

After the successful intubation, the nurse performs a rapid assessment of Ms. D and documents the findings: "Apical pulse irregularly irregular. Face flushed and warm. Extremities cool and mottled. Breath sounds audible bilaterally with crackles present in lung bases. Reports pain with suprapubic palpation. Urine is amber and cloudy, with red streaks. 100 mL urine output when Foley catheter inserted." The patient's current vital sign values and capillary blood glucose are as follows: BP: 86/40 HR: 102 bpm O2 Sat: 93% RR: 32 breaths/min Temp: 103F Blood Glucose: 167 Which data collected about this patient are most important in alerting the nurse to a diagnosis of sepsis and systemic inflammatory response syndrome (SIRS)? SATA A. Hematuria B. Atrial fibrillation C. Temperature D. Apical pulse rate E. Blood glucose level F. Respiratory rate

A. Hematuria C. Temperature D. Apical pulse rate F. Respiratory rate

For which indications would the nurse be prepared to administer a colloid product? SATA A. Hemorrhagic shock B. Dehydration C. Peripheral tissue hypoxia D. Fluid replacement E. Restore osmotic pressure F. Increase hematocrit and hemoglobin levels

A. Hemorrhagic shock C. Peripheral tissue hypoxia E. Restore osmotic pressure F. Increase hematocrit and hemoglobin levels

A young woman comes to the emergency department (ED) with lightheadedness and "a feeling of impending doom". Pulse is 110 beats/min; respirations are 30/min; and blood pressure is 140/90 mm Hg. Which factors does the nurse ask about that could contribute to shock? SATA A. Recent accident or trauma B. Prolonged diarrhea or vomiting C. History of depression or anxiety D. Possibility of pregnancy E. Use of over-the-counter medications F. Recent hospitalization

A. Recent accident or trauma B. Prolonged diarrhea or vomiting D. Possibility of pregnancy E. Use of over-the-counter medications

The unlicensed assistive personnel (UAP) working under supervision of an RN is checking vital signs on the patient at risk for hypovolemic shock. Which instructions must the nurse give the UAP? A. Report any increase in heart rate because it is an early sign of shock B. Report any increased systolic pressure, which is an early sign of shock C. Report any changes in body temperature, which may indicate sepsis D. Report any increase in respiratory rate because of acid-base changes

A. Report any increase in heart rate because it is an early sign of shock

The nursing student takes the morning blood pressure of a postoperative patient, and the reading is 90/50 mm Hg. What does the student do next? SATA A. Report the reading to the primary nurse as a possible sign of hypovolemia B. Assess the patient for subjective feelings of dizziness or shortness of breath C. Check the patient's chart for trends in morning vital sign readings D. Notify the instructor to verify the significance of the finding E. Call a "code blue" F. Place the patient in reverse Trendelenburg position

A. Report the reading to the primary nurse as a possible sign of hypovolemia B. Assess the patient for subjective feelings of dizziness or shortness of breath C. Check the patient's chart for trends in morning vital sign readings D. Notify the instructor to verify the significance of the finding

Based on the assessment data and vital signs, which collaborative actions should the nurse anticipate at this time? SATA A. Send specimens for blood and urine culture B. Start norepinephrine infusion at 8 mcg/min C. Give normal saline bolus of 30 mL/kg D. Draw blood for serum lactate level E. Administer vancomycin 1 g IV

A. Send specimens for blood and urine culture C. Give normal saline bolus of 30 mL/kg D. Draw blood for serum lactate level E. Administer vancomycin 1 g IV

Which statements about shock are true? SATA A. Shock is a whole-body response to tissues not receiving enough oxygen B. Shock is widespread abnormal cellular metabolism C. Shock occurs only in the acute care setting D. Shock may occur in older adults in response to urinary tract infections E. Shock is mostly classified as a disease F. Shock affects all body organs

A. Shock is a whole-body response to tissues not receiving enough oxygen B. Shock is widespread abnormal cellular metabolism D. Shock may occur in older adults in response to urinary tract infections F. Shock affects all body organs

After infusion of the normal saline bolus, Ms. D's blood pressure is 92/42. Lactate level is elevated at 36. Norepinephrine infusion is prescribed at 8 mcg/min and infusion is started through a peripheral IV line. When assessing the norepinephrine infusion site, the nurse notes that the skin around the IV insertion site is cool and pale. Which action should be taken first? A. Shut off the infusion pump B. Assess for pain at the site C. Notify the HCP about the possible norepinephrine extravasation D. Inject the pale area with phentolamine solution per hospital protocol

A. Shut off the infusion pump

A patient with hypovolemic shock is receiving an infusion of dopamine. Which nursing interventions are essential when a patient is receiving this drug? SATA A. Take the blood pressure at least every 15 minutes B. Monitor urine output every hour C. Cover the infusion bag to protect it from light D. Assess the patient for chest pain E. Check the infusion site every 30 minutes for extravasation F. Ask a patient receiving this drug about headaches

A. Take the blood pressure at least every 15 minutes B. Monitor urine output every hour D. Assess the patient for chest pain E. Check the infusion site every 30 minutes for extravasation F. Ask a patient receiving this drug about headaches

At the end of the shift, the supervisor consults with the nurse about which of these oncoming staff members should be assigned to care for Ms. D. Which RN will be best to assign to care for this patient? A. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months B. Newly graduated RN who has worked in the ICU as a nursing assistant and has finished the precepted orientation C. Experienced ICU RN who has been called in on a day off to work for the first 4 hours of the shift D. RN who has been floated from the postanesthesia care unit (PACU) to the ICU for the shift

A. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months

The nurse is preparing for a teaching session for a patient at risk for septic shock. Which topic does the nurse include in this teaching? SATA A. Wash hands frequently using antimicrobial soap B. Avoid aspirin and aspirin-containing products C. Avoid large crowds or gatherings where people might be ill D. Do not share eating utensils E. Wash toothbrushes in a dishwasher F. Take temperature once a week

A. Wash hands frequently using antimicrobial soap C. Avoid large crowds or gatherings where people might be ill D. Do not share eating utensils E. Wash toothbrushes in a dishwasher

The nurse is reviewing the laboratory results of a patient with a systemic infection. What is the significance of a "left shift" in the differential leukocyte count? A. Expected finding because the patient has a serious infection B. Indication that the infection is progressing toward resolution C. Indication that the infection is outpacing the white cell production D. Important to watch for trends but otherwise not urgently significant

C. Indication that the infection is outpacing the white cell production

When the nurse is infusing the normal saline, which action is most important in evaluating for an adverse reaction to the rapid fluid infusion? A. Palpating for any peripheral edema B. Monitoring urinary output C. Listening to lung sounds D. Checking for jugular venous distention

C. Listening to lung sounds

Which patient is at risk for obstructive shock? A. Patient with a history of angina B. Patient with chronic atrial fibrillation C. Patient with pulmonary embolism D. Patient with a history of heart failure

C. Patient with pulmonary embolism

The nurse is caring for a patient at risk for sepsis. Why does the nurse closely monitor the patient for early signs of shock? A. The patient is unable to self-identify or report these early signs B. Distributive shock usually begins as a bacterial or fungal infection C. Prevention of septic shock is easier to achieve in the early phase D. There is widespread vasodilation and pooling of blood in some tissues

C. Prevention of septic shock is easier to achieve in the early phase

The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hyperdynamic state. Several hours later, the patient has a rapid respiratory rate, decreased urine output, and altered level of consciousness. How does the nurse interpret this change? A. A positive response and a signal of recovery B. Temporary situation that is likely to normalize C. Worsening of the condition rather than improvement D. Expected response to standard therapies

C. Worsening of the condition rather than improvement

The student nurse is assessing a patient's mental status because of the patient's risk for decreased tissue perfusion. The supervising nurse intervene when the student nurse asks the patient which question? A. "What is today's date?" B. "Who is the president of this country?" C. "Where are we right now?" D. "Is your name Mr. John Smith?"

D. "Is your name Mr. John Smith?"

A 70-year-old man is admitted to the hospital with an infected finger for several days' duration. He is lethargic and confused and has a temperature of 101.3. Other assessment findings include blood pressure of 94/50 mm Hg, pulse 105 beats/min, respirations of 40/min, and shallow breathing. These assessment findings indicate which type of shock? A. Hypovolemic B. Cardiogenic C. Anaphylactic D. Septic

D. Septic

Which statement about the systematic effects of shock is correct? A. The liver is essentially unaffected, but liver enzymes may be lower than normal B. The current heart rate and blood pressure indicate the cardiac system is at baseline C. The brain and neurologic system can withstand 10-15 minutes of severe hypoperfusion D. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage

D. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage