Shock

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first?

Administer an epinephrine injection as ordered by the health care provider.

Older adults with impaired cardiac function are more likely to develop which type of shock?

Cardiogenic shock

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?

Elevate the legs higher than the heart.

A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following would the nurse do first?

Establish a suitable IV site.

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices?

Hanging tape on the bedside table when changing a wet-to-dry sterile dressing

What is the major clinical use of dobutamine?

Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery.

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible and pulse rhythm changes from regular to irregular.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?

An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition?

An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:

Blood pressure.

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?

Brain Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety.

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?

Increase the force of myocardial contraction

You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client?

Increases myocardial contractility

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed?

dehiscence

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

hypovolemia

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?

70%

Which pulse pressure indicates shock?

90/70 mm HG

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:

MI

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Maintain activity restriction to bedrest.

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?

Multiple organ failure

A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing?

Neurogenic shock

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?

levophed

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess

lung sounds

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption?

morphine

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?

n the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin.

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?

neurogenic shock

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn mediciations would the nurse administer next?

ondansetron

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?

organ damage

The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of:

respiratory failure.

When a client is in the compensatory stage of shock, which symptom occurs?

tachycardia

The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of the client

with an overwhelming bacterial infection.

A patient is in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse?

The healthcare team needs room to do procedures to help your family member, so it would be best if you stayed in the waiting area."

The nurse is conducting an educational class regarding the use of the intraosseous site for administration of fluid to the pediatric client experiencing an emergency, such as shock. What would the nurse include in this educational presentation?

The intraosseous site is preferred if peripheral access cannot be attained rapidly.

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?

WBC Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock.

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy:

When a client has an intra-aortic balloon counterpulsation, he or she is at risk for circulatory problems in the leg in which the catheter has been inserted. In this case, it is the right leg. A complication would be a right foot that is cooler than the left foot