Shock and MODS
Morphine sulfate has which of the following effects on the body? a. Reduces preload b. Increases preload c. Increases afterload d. No effect on preload or afterload
a. Reduces preload Rationale: In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).
The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? a. 0.9% sodium chloride b. Lactated Ringer's c. Albumin d. Dextran
b. Lactated Ringer's Rationale: Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.
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? a. 40% b. 50% c. 60% d. 70%
d. 70% Rationale: Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.
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? a. Levophed b. Dobutrex c. Nipride d. Adrenalin
a. Levophed Rationale: The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.
A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? a. Modified Trendelenburg b. Trendelenburg c. Semi-Fowler's d. Supine
a. Modified Trendelenburg Rationale: The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.
The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? a. Slow the heart rate b. Increase the force of myocardial contraction c. Depress the central nervous system d. Dilate the bronchial tree
b. Increase the force of myocardial contraction Rationale: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.
The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? a. Central venous pressure of 6 mm Hg b. Mean arterial pressure of 70 mm Hg c. Urine output of 0.2 mL/kg/hr d. ScvO2 of 60%
b. Mean arterial pressure of 70 mm Hg Rationale: The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.
Which positioning strategy should be used for a client diagnosed with hypovolemic shock? a. Supine b. Modified Trendelenburg c. Prone d. Semi-Fowler
b. Modified Trendelenburg Rationale: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.
When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? a. Compensatory b. Progressive c. Refractory d. Irreversible
b. Progressive Rationale: In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.
A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as a. Hypovolemic b. Progressive c. Neurogenic d. Compensatory
b. Progressive Rationale: The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin.
Which type of shock is caused by an infection? a. Cardiogenic b. Septic c. Hypovolemic d. Anaphylactic
b. Septic Rationale: Septic shock is caused by an infection. Cardiogenic shock occurs when the heart has an impaired pumping ability. Hypovolemic shock occurs when intravascular volume is decreased. Anaphylactic shock is caused by a hypersensitivity reaction.
The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? a. Within normal limits b. Thready c. 24 d. Palpable
c. 24 Rationale: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse.
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: a. Valvular damage. b. Cardiomyopathies. c. A myocardial infarction. d. Arrhythmias.
c. A myocardial infarction. Rationale: Cardiogenic shock is seen most frequently as a result of a myocardial infarction.
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? a. Hormone antagonist drugs b. Antimetabolite drugs c. Adrenergic drugs d. Anticholinergic drugs
c. Adrenergic drugs Rationale: Adrenergic drugs are the main medications used to treat shock due to their action on the receptors of the sympathetic nervous system.
When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a. Brachial artery b. Radial artery c. Aorta d. Right ventricular wall
c. Aorta Rationale: Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall.
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? a. Rubbing the hands together with antiseptic solution until dry when exiting the client's room b. Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids c. Hanging tape on the bedside table when changing a wet-to-dry sterile dressing d. Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration
c. Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Rationale: The Centers for Disease Control and Prevention do not recommend hanging tape on bedside tables, siderails, linens, or clothing to use for dressings. The other options are activities that are proper infection control practices.
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? a. Limit interaction with visitors. b. Avoid heavy meals. c. Maintain activity restriction to bedrest. d. Arrange personal care supplies nearby.
c. Maintain activity restriction to bedrest. Rationale: Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.
When a client is in the compensatory stage of shock, which symptom occurs? a. Bradycardia b. Urine output of 45 cc/hour c. Tachycardia d. Respiratory acidosis
c. Tachycardia Rationale: The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.
The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? a. The difference between an apical and radial pulse b. The difference between an upper extremity and lower extremity blood pressure c. The difference between the systolic and diastolic pressure d. The difference between the arterial and venous blood pressure
c. The difference between the systolic and diastolic pressure Rationale: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.
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? a. Hemoglobin: 14.2 g/dL b. Potassium: 4.8 mEq/L c. WBC: 42,000/mm3 d. ESR: 19 mm/hour
c. WBC: 42,000/mm3 Rationale: 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. The other lab values are within normal limits.
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a. A full liquid diet b. Isotonic enteral nutrition every 6 hours c. An infusion of crystalloids at an increased rate of flow d. A continuous infusion of total parenteral nutrition
d. A continuous infusion of total parenteral nutrition Rationale: Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.
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? a. Liver b. Kidneys c. Lungs d. Brain
d. Brain Rationale: The body displays a "fight-or-flight" response, with the release of catecholamines. 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.
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? a. Obstructive b. Hypovolemic c. Carcinogenic d. Circulatory (distributive)
d. Circulatory (distributive) Rationale: Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.
What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? a. Reduced preload. b. Reduced afterload. c. Increased cardiac output. d. Decreased blood pressure.
d. Decreased blood pressure. Rationale: A potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently according to the manufacturer's recommendation and institutional policy.
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? a. Pericardiocentesis b. Thoracotomy with chest tube insertion c. Administration of oxygen via venture mask d. Intubation and mechanical ventilation
d. Intubation and mechanical ventilation Rationale: Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Pericardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.
The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? a. Increase in diastolic pressure b. Decrease in respiratory rate c. Increase in systolic blood pressure d. Narrowed pulse pressure
d. Narrowed pulse pressure Rationale: Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.
Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? a. Refractory b. Compensatory c. Irreversible d. Progressive
d. Progressive Rationale: In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.
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. A rapid, bounding pulse b. A slow but steady pulse c. A weak and thready pulse d. A slow and imperceptible pulse
a. A rapid, bounding pulse Rationale: 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.
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a. Administers oxygen by nasal cannula at 2 liters per minute b. Re-assesses the vital signs c. Contacts the admitting physician d. Calls the Rapid Response Team
a. Administers oxygen by nasal cannula at 2 liters per minute Rationale: The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.
Which colloid is expensive but rapidly expands plasma volume? a. Albumin b. Dextran c. Lactated Ringer solution d. Hypertonic saline
a. Albumin Rationale: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.
What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. a. Assess the client who is at risk for shock. b. Administer vasoconstrictive medications to clients at risk for shock. c. Administer prophylactic packed red blood cells to clients at risk for shock. d. Administer intravenous fluids. e. Monitor for changes in vital signs.
a. Assess the client who is at risk for shock. d. Administer intravenous fluids. e. Monitor for changes in vital signs. Rationale: Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.
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: a. Blood pressure. b. Breath sounds. c. Renal output. d. Heart rate.
a. Blood pressure. Rationale: By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: a. Constrict blood vessels in the cardiorespiratory system. b. Decrease heart rate. c. Relax the bronchioles. d. Vasodilate the skeletal muscles.
a. Constrict blood vessels in the cardiorespiratory system. Rationale: Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.
A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to a. Encourage the family to touch and talk to the client. b. Inform the family that everything is being done to assist with the client's survival. c. Open up discussion among the family members about nursing home placement. d. Contact a spiritual advisor to provide comfort to the family.
a. Encourage the family to touch and talk to the client. Rationale: The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.
Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a. Famotidine (Pepcid) b. Nizatidine c. Lansoprazole d. Desmopressin e. Furosemide
a. Famotidine (Pepcid) b. Nizatidine c. Lansoprazole Rationale: Antacids, H2 blockers (Pepcid, Axid), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Desmopressin (DDVAP) is used in the treatment of diabetes insipidus. Furosemide (Lasix) is a loop diuretic and does not prevent ulcer formation.
A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. a. Increased paCO² levels b. Reports of chest pain c. Loss in consciousness d. Ecchymoses and petechiae e. Decreases in liver enzymes
a. Increased paCO² levels b. Reports of chest pain c. Loss in consciousness d. Ecchymoses and petechiae Rationale: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activities of the liver are impaired, and liver enzymes will increase.
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: a. Oxygen at 2 L/min by nasal cannula b. Morphine 2 mg intravenously c. NS at 60 mL/hr via an intravenous line d. Dopamine (Intropin) intravenous solution
a. Oxygen at 2 L/min by nasal cannula Rationale: 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. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.
A client receives alteplase (t-PA). It is most important for the nurse to intervene when a. The client's Glasgow Coma Score changes from 15 to 13. b. A small amount of bleeding occurs at venous puncture sites. c. The client reports joint pain in the knees and elbows. d. The client's cardiac rhythm changes to normal sinus with few PVCs.
a. The client's Glasgow Coma Score changes from 15 to 13. Rationale: Alteplase is a thrombolytic. It is important for the nurse to assess for bleeding. A change in the Glasgow Coma Score may indicate cerebral hemorrhage. Bleeding at venous puncture sites and possibly in the joints is less critical. A normal sinus rhythm with few premature ventricular contractions may be an improvement in the client's cardiac status and indicates lysis of thrombi in the coronary arteries.
The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient? a. The patient has developed a stress ulcer that is bleeding. b. The patient is having a reaction to the vasoconstricting medications. c. The patient has a tumor in the esophagus. d. The patient has bleeding esophageal varices.
a. The patient has developed a stress ulcer that is bleeding. Rationale: GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus.
A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply. a. antacids b. H2 blockers c. proteases d. proton pump inhibitors d. promotility agents
a. antacids b. H2 blockers d. proton pump inhibitors Rationale: Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, H2 blockers [e.g., famotidine (Pepcid)], and proton pump inhibitors [e.g., lansoprazole (Prevacid), esomeprazole magnesium (Nexium)] are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Proteases and peptidases split proteins into small peptides and amino acids and help with digestion. A promotility agent such as metoclopramide is used to decrease nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite.
What is the major clinical use of dobutamine? a. increase cardiac output. b. prevent sinus bradycardia. c. treat hypotension. d. treat hypertension.
a. increase cardiac output. Rationale: Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
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 medications would the nurse administer next? a. ondansetron b. meperidine c. magnesium hydroxide d. loperamide
a. ondansetron Rationale: An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).
A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? a. "Monitor urine output every hour." b. "Infuse I.V. fluids at 83 ml/hour." c. "Administer oxygen by nasal cannula at 3 L/minute." d. "Draw samples for hemoglobin and hematocrit every 6 hours."
b. "Infuse I.V. fluids at 83 ml/hour." Rationale: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.
A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? a. Two large-bore IVs and begin crystalloid fluids b. 100% oxygen via a nonrebreather mask c. C-spine x-rays d. Type and cross match
b. 100% oxygen via a nonrebreather mask Rationale: The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied via a nonrebreather mask. The other orders should be completed after the client's airway is secure.
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? a. Blood products b. 5% albumin c. 6% dextran d. 6% hetastarch
b. 5% albumin Rationale: Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared to crystalloid solutions. Hetastarch and dextran solutions are not indicated for fluid administration because these agents interfere with platelet aggregation. Blood products are not indicated in this situation.
A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits a. A change in apical pulse rate from 102 to 88 beats/min b. Adventitious breath sounds c. Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute d. Troponin levels less than 0.35 ng/mL
b. Adventitious breath sounds Rationale: The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.
A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is a. A young female adolescent who developed shock from tampon use during menses b. An older adult man with end-stage renal disease and an infected dialysis access site c. An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection d. A middle-aged woman with metastatic breast cancer and a BMI of 26
b. An older adult man with end-stage renal disease and an infected dialysis access site Rationale: MODS may develop when a client experiences septic shock. Those at increased risk for MODS are older clients, clients who are malnourished, and clients with coexisting disease.
The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? a. Stress ulcer b. Disseminated intravascular coagulation (DIC) c. Septicemia d. Stevens-Johnson syndrome from the administration of antibiotics
b. Disseminated intravascular coagulation (DIC) Rationale: Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (e.g., prothrombin time [PT], activated partial thromboplastin time [aPTT]) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. The other conditions listed would not result in bleeding simultaneously at multiple sites.
You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? a. Shock begins in the decompensation stage. b. In the compensation stage, catecholamines are released. c. Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage. d. The renin-angiotensin-aldosterone system fails in the compensation stage.
b. In the compensation stage, catecholamines are released. Rationale: Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage.
The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? a. Decreased white blood cell count b. Increase in arterial oxygenation c. Decreased depressive symptoms d. Regulation of sodium and potassium
b. Increase in arterial oxygenation Rationale: Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.
You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do? a. Decreases peripheral blood flow b. Increases catecholamine secretion c. Increases the production of antidiuretic hormone d. Restores blood pressure
d. Restores blood pressure Rationale: The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone.
