Shock NCLEX Questions, Nclex Questions for Shock - Critical Care, Sepsis NCLEX, Ch 67: shock, SIRS, MODS
A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. nitroglycerine (Tridil). b. dobutamine (Dobutrex). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
B AND C
A 40-year-old man with a history of IV drug use presents with cellulitis with multiple abscesses of the right upper extremity. His current weight is 70 kg (lean body weight). He rapidly develops worsening respiratory distress and hypotension and ultimately requires intubation and mechanical ventilation. Blood gas analysis shows a pH of 7.23, Paco2 of 58 torr, Pao2 of 60 torr, and an oxygen saturation of 88%. His ventila- tor settings are assist-control mode with a tidal vol- ume of 420 mL, respiratory rate of 16 breaths/min,positive end-expiratory pressure (PEEP) of 5 cm H2O, and Fio2 of 70%. His plateau pressure on the ventilator is 29 cm H2O. A chest radiograph shows bilateral interstitial infiltrates, and a 2-dimensional echocardiogram demonstrates normal left ventricular function. What ventilator adjustments should be made? (A) Change the ventilator mode to synchronized intermittent mandatory ventilation (B) Increase PEEP (C) Increase respiratory rate to 24 breaths/min (D) Increase tidal volume to 600 mL (E) Leave the ventilator settings unchanged
(B) Increase PEEP. The largest trial of a volume and pressure-limited strategy showed a 9% decrease in all-cause mortality in patients ventilated with tidal volumes of 6 mL/kg of estimated lean body weight as compared with a tidal volume of 12 mL/kg (target plateau pressure, < 30 cm H2O).3 Based on the results of this study, a strategy of using low tidal volume and high PEEP is recommended for mechanical ventilation of acute lung injury/ARDS patients.
Which of the following is true of vasopressin in septic shock? (A) Continuous infusion at low doses improves 28-day overall mortality (B) Continuous infusion at low doses improves mortality in patients with severe septic shock (C) Continuous infusion at low doses increases cardiac output (D) Continuous infusion at low doses reduces the catecholamine infusion requirement
(D) Continuous infusion at low doses reduces the catecholamine infusion requirement. Vasopressin is a peptide synthesi zed in the hypothalamus and released from the posterior pituitary. Vasopressin produces a wide range of physiologic effects, including blood pressure maintenance. Acting through vascular V1receptors, the endogenous hormone directly induces vasoconstriction in hypotensive patients but does not significantly alter vascular smooth muscle constriction in humans with normal blood pressure. Landry and colleagues8 demonstrated that patients with septic shock had inappropriately low levels of serum vasopressin compared with patients with cardiogenic shock, who had normal or elevated levels. In addition, they demonstrated that supplementing a low-dose infusion of vasopressin in septic shock patients allowed for the reduction or removal of the other catecholamine vasopressors. This was seen de- spite a reduction in cardiac output. Although these results were duplicated in subsequent studies, none evaluated outcomes such as length of stay or mortal- ity until recently. A randomized double-blind study comparing vasopressin versus norepinephrine for the treatment of septic shock demonstrated no dif- ference in 28-day mortality between the 2 treatment groups.9 Subgroup analysis of patients with severe septic shock, defined as requiring 15 μg/min of norepinephrine or its equivalent, also did not demonstrate a mortality benefit. However, patients with less severe septic shock (ie, requiring 5-15 μg/min of norepinephrine) experienced a trend toward lower mortality when treated with low-dose (0.01-0.03 U/min) vasopressin.
A 70-year-old man presents to the emergency de- partment with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate. What is the first step in the initial management of this patient? (A) Antibiotic therapy (B) β-Blocker therapy to control heart rate (C) Intravenous (IV) fluid resuscitation (D) Supplemental oxygen and airway management (E) Vasopressor therapy with dopamine
(D) Supplemental oxygen and airway management. The initial evaluation of any critically ill patient in shock should include assessing and establishing an airway, evaluating breathing (which includes consideration of mechanical ventilator support), and restoring adequate circulation.2 Adequate oxygenation should be ensured with a goal of achieving an arterial oxygen saturation of 90% or greater.
Which of the following patients is an ideal candi- date for noninvasive positive pressure ventilation (NIPPV)? (A) A 30-year-old comatose woman suspected of drug overdose (B) A 55-year-old man with acute anterior wall myocardial infarction with cardiogenic shock and recurrent ventricular arrhythmias (C) A 60-year-old man with peritonitis requiring 2 vasopressors (D) A 65-year-old patient with a massive stroke and inability to protect airway (E) A 70-year-old alert patient with respiratory failure due to chronic obstructive pulmonary disease exacerbation
(E) A 70-year-old alert patient with respiratory failure due to chronic obstructive pulmonary disease exacerbation. NIPPV can be considered in carefully selected patients with sepsis. Patients with shock, altered mental status, or increased airway secretions should not be treated with NIPPV.4 Studies regarding the use of NIPPV in patients with sepsis-induced acute lung injury/ARDS are limited. In our experience, patients with normal mental status who are likely to recover within 48 to 72 hours seem to be good candidates for NIPPV.
A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a. The cardiac output is elevated. b. The central venous pressure (CVP) is increased. c. The systemic vascular resistance (SVR) is high. d. The PAWP is high.
A
A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a. urine output of 0.5 ml/kg/hr. b. decreased peripheral edema. c. decreased CVP. d. oxygen saturation 90% or more.
A
A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate a. administration of furosemide (Lasix) IV. b. titration of an epinephrine (Adrenalin) drip. c. administration of a normal saline bolus. d. assisting with endotracheal intubation.
A
All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who develops severe respiratory distress and faintness. Which one will the nurse administer first? a. Epinephrine (Adrenalin) b. Normal saline infusion c. Dexamethasone (Decadron) d. Diphenhydramine (Benadryl)
A
The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a. urine output is 40 ml over the last hour. b. hemoglobin is within normal limits. c. CVP has decreased. d. mean arterial pressure (MAP) is 65 mm Hg.
A
When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the a. cardiac output is increased and the central venous pressure (CVP) is low. b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low. c. heart rate is decreased, and the systemic vascular resistance is low. d. cardiac output is decreased and the PAWP is high.
A
When caring for a patient in acute septic shock, what should the nurse anticipate? A. Infusing large amounts of IV fluids B. Administering osmotic and/or loop diuretics C. Administering IV diphenhydramine (Benadryl) D. Assisting with insertion of a ventricular assist device (VAD)
A
While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient's bed is elevated to 75 degrees. This finding indicates a need for a. additional fluid replacement. b. antibiotic administration. c. infusion of a sympathomimetic drug. d. administration of increased oxygen.
A
When caring for a patient in acute septic shock, what should the nurse anticipate? a- Infusing large amounts of IV fluids b- Administering osmotic and/or loop diuretics c- Administering IV diphenhydramine (Benadryl) d- Assisting with insertion of a ventricular assist device (VAD)
A- Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock.
1. The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Infuse vasopressin (Pitressin) 0.01 units/min. d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.
ANS: E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.
11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine? a. The patient's central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min. d. The patient has had no urine output since being admitted.
ANS: A Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine? a. The patient's central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min. d. The patient has had no urine output since being admitted.
ANS: A Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration. DIF: Cognitive Level: Application REF: 1733-1735 | 1736 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
15. A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Infuse drotrecogin- (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.
ANS: A Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.
15. A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Infuse drotrecogin- (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.
ANS: A Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well. DIF: Cognitive Level: Application REF: 1735-1737 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
1. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c. Administer hydrocortisone (SoluCortef) 100 mg IV. d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.
ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.
1. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c. Administer hydrocortisone (SoluCortef) 100 mg IV. d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.
ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate. DIF: Cognitive Level: Application REF: 1724-1726 | 1731 | 1733 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
17. When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? a. BP 92/56 mm Hg b. Skin cool and clammy c. Apical pulse 118 beats/min d. Arterial oxygen saturation 91%
ANS: B Since patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information also will be reported, but does not indicate deterioration of the patient's status.
Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective? A. Urine output increase from 5 mL/hr to 25 mL/hr B. Pulse pressure decrease from 35 mm Hg to 28 mm Hg C. Respiratory rate increase from 22 breaths/min to 26 breaths/min D. Core body temperature increase from 98.2 F (36.8 C) to 98.8 F (37.1 C)
ANS: A Rationale: During shock, the kidneys and baroreceptors sense an ongoing decrease in MAP and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase.
21. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? a. The patient's IV infusion site is cool and pale. b. The patient has warm, dry skin on the extremities. c. The patient has an apical pulse rate of 58 beats/min. d. The patient's urine output has been 28 mL over the last hour.
ANS: A The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28 mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.
21. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? a. The patient's IV infusion site is cool and pale. b. The patient has warm, dry skin on the extremities. c. The patient has an apical pulse rate of 58 beats/min. d. The patient's urine output has been 28 mL over the last hour.
ANS: A The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28 mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action. DIF: Cognitive Level: Application REF: 1733-1734 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
14. Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient has crackles throughout both lung fields. d. The patient's extremities are cool and pulses are weak.
ANS: A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patient's diagnosis of cardiogenic shock.
14. Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient has crackles throughout both lung fields. d. The patient's extremities are cool and pulses are weak.
ANS: A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patient's diagnosis of cardiogenic shock. DIF: Cognitive Level: Application REF: 1740-1741 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
18. A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. attach a cardiac monitor. c. obtain the blood pressure. d. check the level of consciousness.
ANS: A The initial actions of the nurse are focused on the ABCs—airway, breathing, circulation—and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.
18. A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. attach a cardiac monitor. c. obtain the blood pressure. d. check the level of consciousness.
ANS: A The initial actions of the nurse are focused on the ABCs—airway, breathing, circulation—and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration. DIF: Cognitive Level: Application REF: 1729-1731 | 1732 | 1733 | 1736-1737 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
2. A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg. d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient. DIF: Cognitive Level: Application REF: 1719 | 1721-1722 | 1735 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
2. A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg. d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.
1. A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. d. Administer large volumes of lactated Ringer's solution. e. Administer high-flow oxygen (100%) by non-rebreather mask.
ANS: A, B, C, E All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.
1. A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. d. Administer large volumes of lactated Ringer's solution. e. Administer high-flow oxygen (100%) by non-rebreather mask.
ANS: A, B, C, E All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate. DIF: Cognitive Level: Application REF: 1736-1737 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
9. Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.
ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.
9. Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.
ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. DIF: Cognitive Level: Application REF: 1733-1735 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
23. Which information about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the heath care provider? a. The patient's heart rate is 108 beats/min. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's urine output is 15 mL/hr.
ANS: B Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy.
23. Which information about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the heath care provider? a. The patient's heart rate is 108 beats/min. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's urine output is 15 mL/hr.
ANS: B Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy. DIF: Cognitive Level: Application REF: 1735-1736 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
22. The following therapies are prescribed by the health care provider for a patient who has respiratory distress and syncope after a bee sting. Which will the nurse administer first? a. normal saline infusion b. epinephrine (Adrenalin) c. dexamethasone (Decadron) d. diphenhydramine (Benadryl)
ANS: B Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions also are appropriate but would not be the first ones administered.
22. The following therapies are prescribed by the health care provider for a patient who has respiratory distress and syncope after a bee sting. Which will the nurse administer first? a. normal saline infusion b. epinephrine (Adrenalin) c. dexamethasone (Decadron) d. diphenhydramine (Benadryl)
ANS: B Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions also are appropriate but would not be the first ones administered. DIF: Cognitive Level: Application REF: 1736-1737 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A. 75-year-old man with hypertension and early Alzheimer's disease B. 68-year-old woman 2 days postoperative from bowel surgery C. 80-year-old community-dwelling man with no other health problems undergoing cataract surgery D. 54-year-old woman with moderate asthma and severe degenerative joint disease of the right knee
ANS: B Rationale: The 68-year-old woman has several risk factors. First she is an older adult, and immune function decreases with age. The greatest risk factor is that she has just had bowel surgery. Not only does major surgery further reduce the immune response, the bowel cannot be "sterilized" for surgery. Therefore the usual bacteria of the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted.
17. When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? a. BP 92/56 mm Hg b. Skin cool and clammy c. Apical pulse 118 beats/min d. Arterial oxygen saturation 91%
ANS: B Since patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information also will be reported, but does not indicate deterioration of the patient's status. DIF: Cognitive Level: Application REF: 1723 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate a. infusion of 5% human albumin. b. administration of furosemide (Lasix) IV. c. titration of an epinephrine (Adrenalin) drip. d. administration of hydrocortisone (SoluCortef).
ANS: B The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. Normal saline infusion would increase the PAWP further. Hydrocortisone might be used for septic or anaphylactic shock.
7. A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate a. infusion of 5% human albumin. b. administration of furosemide (Lasix) IV. c. titration of an epinephrine (Adrenalin) drip. d. administration of hydrocortisone (SoluCortef).
ANS: B The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. Normal saline infusion would increase the PAWP further. Hydrocortisone might be used for septic or anaphylactic shock. DIF: Cognitive Level: Application REF: 1735 | 1736 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
12. When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective? a. No heart murmur is audible. b. Skin is warm, pink, and dry. c. Troponin level is decreased. d. Blood pressure is 90/40 mm Hg.
ANS: B Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.
12. When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective? a. No heart murmur is audible. b. Skin is warm, pink, and dry. c. Troponin level is decreased. d. Blood pressure is 90/40 mm Hg.
ANS: B Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock. DIF: Cognitive Level: Application REF: 1721 | 1723 | 1733-1735 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
8. The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. 500 mL of 5% albumin. b. lactated Ringer's solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.
ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, crystalloids should be used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the initial therapy for hypovolemic shock.
8. The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. 500 mL of 5% albumin. b. lactated Ringer's solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.
ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, crystalloids should be used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. DIF: Cognitive Level: Application REF: 1731 | 1732 | 1733 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
3. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2° F (38.4° C)
ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.
3. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2° F (38.4° C)
ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock. DIF: Cognitive Level: Comprehension REF: 1721-1722 | 1723 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
16. When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Decreasing the room temperature to 68° F for a patient with neurogenic shock d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
ANS: C Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.
16. When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Decreasing the room temperature to 68° F for a patient with neurogenic shock d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
ANS: C Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Application REF: 1721-1722 | 1724 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
6. To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse make? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Monitor stools for occult blood. d. Check for abdominal distention.
ANS: C Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the omeprazole administration.
6. To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse make? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Monitor stools for occult blood. d. Check for abdominal distention.
ANS: C Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the omeprazole administration. DIF: Cognitive Level: Application REF: 1735-1737 | 1742-1743 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Avoid elevating head of bed. b. Check temperature every 2 hours. c. Monitor breath sounds frequently. d. Assess skin for flushing and itching.
ANS: C Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.
10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Avoid elevating head of bed. b. Check temperature every 2 hours. c. Monitor breath sounds frequently. d. Assess skin for flushing and itching.
ANS: C Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock. DIF: Cognitive Level: Application REF: 1721 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
ANS: C When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR.
5. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
ANS: C When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR. DIF: Cognitive Level: Application REF: 1731 | 1733-1735 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
13. Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation
ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments also will be expected with effective treatment of anaphylactic shock.
13. Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation
ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments also will be expected with effective treatment of anaphylactic shock. DIF: Cognitive Level: Application REF: 1724-1725 | 1732 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
4. A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion. b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion. d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.
ANS: D Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR.
4. A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion. b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion. d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.
ANS: D Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR. DIF: Cognitive Level: Application REF: 1733-1734 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
Why are the manifestations of most types of shock the same regardless of what specific events or condition caused the shock to occur? A. The blood, blood vessels, and heart are directly connected to each other so that when one is affected, all three are affected. B. Because blood loss occurs with all types of shock, the most common first manifestation is hypotension. C. Every type of shock interferes with oxygenation and metabolism of all cells in the same sequence. D. The sympathetic nervous system is triggered by any type of shock and initiates the stress response.
ANS: D Rationale: Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems.
19. During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation
ANS: D The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.
19. During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation
ANS: D The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock. DIF: Cognitive Level: Application REF: 1728-1729 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
20. A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first? a. Place the patient on continuous cardiac monitor. b. Draw blood to type and crossmatch for transfusions. c. Insert two 14-gauge IV catheters in antecubital space. d. Administer oxygen at 100% per non-rebreather mask
ANS: D The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions also should be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.
20. A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first? a. Place the patient on continuous cardiac monitor. b. Draw blood to type and crossmatch for transfusions. c. Insert two 14-gauge IV catheters in antecubital space. d. Administer oxygen at 100% per non-rebreather mask
ANS: D The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions also should be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented. DIF: Cognitive Level: Application REF: 1732 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. check the blood pressure. b. obtain an oxygen saturation. c. attach a cardiac monitor. d. check level of consciousness.
B
A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a. Insert two 14-gauge IV catheters. b. Administer oxygen at 100% per non-rebreather mask. c. Place the patient on continuous cardiac monitor. d. Draw blood to type and crossmatch for transfusions.
B
A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first? a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl. b. Give normal saline IV at 500 ml/hr. c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg. d. Infuse drotrecogin- (Xigris) 24 mcg/kg.
B
A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a. Administer all medications through the patient's indwelling central line. b. Place the patient in a private room. c. Restrict the patient to foods that have been well-cooked or processed. d. Insert a nasogastric (NG) tube for enteral feeding.
B
Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the drug, the nurse ensures that the a. patient's heart rate is less than 100. b. patient has received adequate fluid replacement. c. patient's urine output is within normal range. d. patient is not receiving other sympathomimetic drugs.
B
The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include a. pH 7.48, PaCO2 33 mm Hg. b. pH 7.33, PaCO2 30 mm Hg. c. pH 7.41, PaCO2 50 mm Hg. d. pH 7.38, PaCO2 45 mm Hg.
B
To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are a. stool guaiac and bowel sounds. b. lung sounds and oxygenation status. c. serum creatinine and urinary output. d. serum bilirubin levels and skin color.
B
While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a. cold, mottled extremities. b. restlessness and apprehension. c. a heart rate of 120 and cool, clammy skin. d. systolic BP less than 90 mm Hg.
B
The nurse would recognize which of the following clinical manifestations as suggestive of sepsis? A) Respiratory rate of seven breaths per minute B) Hyperglycemia in the absence of diabetes C) Sudden diuresis unrelated to drug therapy D) Bradycardia with sudden increase in blood pressure
B Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachycardia and tachypnea.
A patient's localized infection has progressed to the point where septic shock is now suspected. Which of the following is an appropriate treatment modality for this patient? A) Insulin infusion B) Aggressive fluid resuscitation C) Intravenous administration of epinephrine D) Administration of nitrates and β-adrenergic blockers
B Patients in septic shock require large amounts of fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).
When caring for a patient in acute septic shock, the nurse would anticipate A) Administering osmotic and/or loop diuretics. B) Infusing large amounts of intravenous fluids. C) Administering intravenous diphenhydramine (Benadryl). D) Assisting with insertion of a ventricular assist device (VAD).
B Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of intravenous fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock, not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock, but would not be helpful with septic shock.
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a- Increased serum albumin b- Decreased respiratory compliance c- Increased gastrointestinal (GI) motility d- Decreased blood urea nitrogen (BUN)/creatinine ratio
B- Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.
The nurse would recognize which clinical manifestation as suggestive of sepsis? a- Sudden diuresis unrelated to drug therapy b- Hyperglycemia in the absence of diabetes c-Respiratory rate of seven breaths per minute d-Bradycardia with sudden increase in blood pressure
B- Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.
A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? a-Obtain a 12-lead ECG and arterial blood gases. b-Rapidly administer 1000 mL normal saline solution IV. c-Administer norepinephrine (Levophed) by continuous IV infusion. d-Carefully insert a nasogastric tube and an indwelling bladder catheter.
B-Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.
A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b. stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.
C
The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. a liter of lactated Ringer's solution. b. 500 ml of 5% albumin. c. two 14-gauge IV catheters. d. a retention catheter.
C
When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS? a. The patient has crackles throughout both lung fields. b. The patient complains of 8/10 crushing chest pain. c. The patient has an elevated ammonia level and confusion. d. The patient has cool extremities and weak pedal pulses.
C
When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and nitroglycerin (Tridil) infusions, the best evidence that the medications are effective is that the a. systolic BP increases to greater than 100 mm Hg. b. cardiac monitor shows sinus rhythm at 96 beats/min. c. PAWP drops to normal range. d. troponin and creatine kinase levels decrease.
C
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? A) Avoid elevating head of bed. B) Check temperature every 2 hours. C) Monitor breath sounds frequently. D) Assess skin for flushing and itching.
C
Which of the following laboratory findings fits with a diagnosis of cardiogenic shock? A) Decreased liver enzymes B) Increased white blood cells C) Increased blood urea nitrogen and creatinine levels D) Decreased red blood cells, hemoglobin, and hematocrit
C The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes while red blood cell indices are typically normal because of relative hypovolemia. White blood cell levels do not typically rise in cardiogenic shock.
Which interventions should be used for anaphylactic shock (select all that apply)? a. Antibiotics b. Vasodilator c. Antihistamine d. Oxygen supplementation e. Colloid volume expansion f. Crystalloid volume expansion
C, D, E Due to the massive vasodilation, release of vasoactive mediators, and increased in capillary permeability from the immediate reaction, fluid leaks from the vascular space into the interstitial space. By administering a colloid (which contain larger particles that do not penetrate the semipermable membrane), the large particles will stay intravascularly. Due to their smaller size particle composition, a crystalloid would not stay intravascularly and leak interstitially.
A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? a-Insulin infusion b- IV administration of epinephrine c- Aggressive IV crystalloid fluid resuscitation d- Administration of nitrates and β-adrenergic blockers
C- Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).
The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? a-Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds b-Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin c-PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites d-Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL
C- Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.
The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? a-Antibiotics are not useful once an infection has progressed to sepsis. b-Weaning the patient away from the ventilator is the top priority in sepsis. c-Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d-The patient has recovered from sepsis if he has warm skin and ruddy cheeks.
C-Patients with sepsis may be normovolemic but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Addititonal respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.
A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: 1. Reduced cardiac output 2. Increased stroke volume 3. Reduced blood volume 4. Blood flow blocked in the pulmonary circulation
Correct Answer: 1 Rationale 1: In cardiogenic shock, cardiac output is reduced, leading to poor tissue perfusion. Rationale 2: In cardiogenic shock, stroke volume is decreased. Rationale 3: There is not a reduction of blood volume in cardiogenic shock. Rationale 4: There is not a blockage of blood flow through the pulmonary circulation in cardiogenic shock.
Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 8 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54%
Correct Answer: 1 Rationale 1: A CVP reading of 8 mm Hg is within normal range and rehydration has been restored. Rationale 2: The mean arterial pressure (MAP) should be between 60 to 70 mm Hg as evidence of positive fluid resuscitation efforts. Rationale 3: Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. Rationale 4: Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid-to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements.
A patient is being treated for pericarditis. The nurse will plan interventions to prevent the onset of which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic
Correct Answer: 1 Rationale 1: Acute pericarditis and the development of fluid accumulation in the pericardial space can lead to the development of obstructive shock. Rationale 2: Pericarditis is not a risk factor for the development of hypovolemic shock. Rationale 3: Pericarditis is not a risk factor for the development of distributive shock. Rationale 4: Pericarditis is not a risk factor for the development of cardiogenic shock.
Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? 1. Reduced wheezing 2. Heart rate 55 and regular 3. Blood pressure 98/50 mm Hg 4. Respiratory rate 28
Correct Answer: 1 Rationale 1: An expected action for epinephrine is bronchodilation as evidenced by less wheezing. Rationale 2: Epinephrine increases heart rate. Rationale 3: Epinephrine increases blood pressure. Rationale 4: Epinephrine lowers the respiratory rate. This respiratory rate indicates that epinephrine has not been effective.
A patient is diagnosed with cardiac tamponade. When planning care, the nurse will include interventions to address which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic
Correct Answer: 1 Rationale 1: Cardiac tamponade can lead to obstructive shock. Rationale 2: Cardiac tamponade will not lead to hypovolemic shock. Rationale 3: Cardiac tamponade will not lead to distributive shock. Rationale 4: Cardiac tamponade will not lead to cardiogenic shock.
A patient is demonstrating signs of obstructive shock but the cause has yet to be determined. Which finding indicates the patient is experiencing a pulmonary embolism as the cause for obstructive shock? 1. Chest pain 2. Hypotension 3. Tachycardia 4. Oliguria
Correct Answer: 1 Rationale 1: Chest pain is a symptom associated with a massive pulmonary embolus. Rationale 2: Hypotension is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus. Rationale 3: Tachycardia is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus. Rationale 4: Oliguria is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus.
A patient is experiencing an anaphylactic reaction to a medication. The nurse is concerned that the patient will develop distributive shock because: 1. The release of histamine causes vasodilation with plasma leakage. 2. Sympathetic innervation is interrupted. 3. Microorganisms overwhelm the vascular system. 4. Parasympathetic innervation functions are unopposed.
Correct Answer: 1 Rationale 1: In an anaphylactic reaction leading to distributive shock, the release of histamine causes vasodilation with plasma leakage. Vasodilation leads to profound hypotension, hypovolemia from fluid extravasation, reduced reload, and reduced cardiac output. Rationale 2: Sympathetic innervation is not interrupted in an anaphylactic reaction. Rationale 3: Microorganisms do not overwhelm the vascular system in an anaphylactic reaction. Rationale 4: Parasympathetic innervation functioning unopposed is not a characteristic of an anaphylactic reaction.
A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? 1. Jugular vein distention 2. Dry mucous membranes 3. Poor skin turgor 4. Thirst
Correct Answer: 1 Rationale 1: Jugular vein distention is a manifestation of cardiogenic shock. Rationale 2: The mucous membranes are not dry in cardiogenic shock. Rationale 3: The skin turgor is not poor in cardiogenic shock. Rationale 4: Thirst is not a manifestation of cardiogenic shock.
The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive
Correct Answer: 1 Rationale 1: One etiology of cardiogenic shock is a myocardial infarction. Rationale 2: Acute myocardial infarction does not cause hypovolemic shock. Rationale 3: Acute myocardial infarction does not cause distributive shock. Rationale 4: Acute myocardial infarction does not cause obstructive shock.
A patient is prescribed vasopressin 0.03 units/minute as treatment for septic shock. What action will the nurse take when providing this medication? 1. Provide the vasopressin infusion in addition to a norepinephrine infusion. 2. Infuse through a peripheral line. 3. Utilize a rapid infuser. 4. Administer with 0.9% normal saline.
Correct Answer: 1 Rationale 1: The dose of 0.03 units/min is usually added to a norepinephrine infusion. Rationale 2: This medication should always be administered via an infusion pump. Rationale 3: A rapid infuser is used to deliver large amounts of warmed crystalloid or blood to a patient over a short period of time. It is not used for medication administration. Rationale 4: This medication does not need to be administered with 0.9% normal saline.
A patient is receiving phenylephrine 50 mcg/min as treatment for shock. Which assessment finding indicates this medication is effective? 1. Blood pressure 110/68 mm Hg 2. Heart rate 110 3. Respiratory rate 12 and regular 4. Decreased peripheral pulses
Correct Answer: 1 Rationale 1: The expected effect of this medication is an increase in blood pressure. Rationale 2: Phenylephrine does not increase the heart rate. Rationale 3: Phenylephrine does not affect the respiratory rate. Rationale 4: Decreased peripheral pulses is a side/toxic effect of this medication.
The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Age 80 2. History of atrial fibrillation 3. Bacteremia 4. T3 spinal cord injury 5. Latex allergy
Correct Answer: 1,2 Rationale 1: Advanced age increases the risk for development of pulmonary emboli, which is one cause of obstructive shock. Rationale 2: Atrial fibrillation increases the risk for developing pulmonary emboli, which is one cause of obstructive shock. Rationale 3: Bacteremia increases a patient's risk of developing septic shock and not obstructive shock. Rationale 4: A spinal cord injury increases the risk for developing distributive shock and not obstructive shock. Rationale 5: A latex allergy increases the risk for developing distributive shock and not obstructive shock.
A patient is receiving norepinephrine 30 mcg/min for treatment of refractory shock. Which assessment findings suggest the patient is experiencing peripheral vasoconstriction from the medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Decreased peripheral pulses 2. Drop in body temperature 3. Onset of paresthesias 4. Drop in blood pressure 5. Increased cardiac output
Correct Answer: 1,2,3 Rationale 1: At high doses of norepinephrine, decreased peripheral pulses indicates significant vasoconstriction. Rationale 2: At high doses of norepinephrine, a drop in body temperature indicates significant vasoconstriction. Rationale 3: At high doses of norepinephrine, paresthesias indicate significant vasoconstriction. Rationale 4: This medication does not cause a drop in blood pressure. Rationale 5: An increase in cardiac output is an expected effect of this medication and does not indicate significant vasoconstriction.
A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Administer epinephrine 1:1000 intramuscularly. 2. Apply oxygen via face mask as prescribed. 3. Provide diphenhydramine 25 mg intravenous. 4. Administer vasopressin. 5. Prepare to administer antithrombolytic agents as prescribed.
Correct Answer: 1,2,3 Rationale 1: Epinephrine produces bronchodilation, improving the respiratory status. The route of administration is initially intramuscular. Rationale 2: Supplemental oxygen is used in the treatment of anaphylactic shock. Rationale 3: Hydrogen ion blockers such as diphenhydramine may be administered to block the histamine effects. Rationale 4: Vasopressin is not used in the treatment of anaphylactic shock. Rationale 5: Antithrombolytic agents are not used in the treatment of anaphylactic shock.
During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Systolic blood pressure 82 mm Hg 2. Capillary refill 10 seconds 3. Crackles bilateral lung bases 4. Heart rate 55 and regular 5. Warm dry skin
Correct Answer: 1,2,3 Rationale 1: Hypotension is a manifestation of cardiogenic shock. Rationale 2: Delayed capillary refill is a manifestation of cardiogenic shock. Rationale 3: Crackles are a manifestation of cardiogenic shock. Rationale 4: Bradycardia is not a manifestation of cardiogenic shock. Rationale 5: Warm dry skin is not a manifestation of cardiogenic shock.
The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations
Correct Answer: 1,2,3 Rationale 1: Hypotension is a manifestation of neurogenic shock because of the loss of autonomic reflexes. Rationale 2: Bradycardia occurs because of the loss of sympathetic innervation. Rationale 3: Warm dry skin occurs because of a loss of cutaneous control of sweat glands. Rationale 4: Abdominal cramping is not a manifestation of neurogenic shock. Rationale 5: Palpitations are not seen in neurogenic shock.
A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Sepsis 2. Spinal cord injury 3. Anaphylaxis 4. Hemorrhage 5. Pulmonary embolism
Correct Answer: 1,2,3 Rationale 1: One etiology of distributive shock is sepsis. Rationale 2: One etiology of distributive shock is spinal cord injury. Rationale 3: One etiology of distributive shock is anaphylaxis. Rationale 4: Hemorrhage is not an etiology of distributive shock. Rationale 5: Pulmonary embolism is not an etiology of distributive shock.
A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Elevated pulmonary arterial wedge pressure 2. Elevated central venous pressure 3. Elevated systemic vascular resistance index 4. Elevated mean arterial pressure 5. Elevated stroke volume
Correct Answer: 1,2,3 Rationale 1: This finding is consistent with pulmonary vascular congestion. Rationale 2: This finding is consistent with fluid volume overload. Rationale 3: This finding is consistent with pulmonary vascular congestion. Rationale 4: This finding is not consistent with cardiogenic shock. Rationale 5: This finding is not consistent with cardiogenic shock.
A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Recent bee sting 2. Ingestion of drugs 3. History of latex allergy 4. Recent diagnostic imaging tests 5. Recent myocardial infarction
Correct Answer: 1,2,3,4 Rationale 1: Venoms such as bee stings can trigger anaphylactic shock. Rationale 2: Drugs can trigger anaphylactic shock. Rationale 3: Latex can trigger anaphylactic shock. Rationale 4: Contrast media for diagnostic tests can trigger anaphylactic shock. Rationale 5: Myocardial infarction is not a trigger for anaphylactic shock.
The nurse is explaining the mechanism of a pulmonary embolism to the family of a patient diagnosed with the disorder. Place in order the steps the nurse will use to instruct the family about this disease process. Standard Text: Click and drag the options below to move them up or down. Choice 1. Blood clot causes backup of blood in the right ventricle. Choice 2. Blood clot blocks blood to the left ventricle. Choice 3. Left ventricle does not get enough blood to pump through the body. Choice 4. Amount of blood the heart has to pump to the body drops. Choice 5. Blood pressure drops. Choice 6. Amount of blood going to the body drops.
Correct Answer: 1,2,3,4,5,6 Rationale 1: The obstruction caused by the pulmonary embolism increases the afterload of the right ventricle, causing right ventricular failure. Rationale 2: The embolus prevents adequate blood flow from the pulmonary circulation to the left ventricle. Rationale 3: Because blood flow from the pulmonary circulation is blocked, left ventricular preload drops. Rationale 4: Because left ventricular preload is decreased, there is not enough blood in the heart to pump, causing decreased cardiac output. Rationale 5: A lack of blood circulating will lead to hypotension. Rationale 6: When the blood is backed up and is not being pumped into the general circulation, tissue perfusion is reduced.
The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Dopamine 2. Norepinephrine 3. Dobutamine 4. Epinephrine 5. Phenylephrine
Correct Answer: 1,2,3,5 Rationale 1: Dopamine is commonly used in the treatment of cardiogenic shock. Rationale 2: Norepinephrine is commonly used in the treatment of cardiogenic shock. Rationale 3: Dobutamine may be used in the patient with cardiogenic shock who has an adequate blood pressure. Rationale 4: Epinephrine is not used in the treatment of cardiogenic shock. Rationale 5: Phenylephrine is a vasopressor and may be used in the patient with cardiogenic shock who is receiving dobutamine.
Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time
Correct Answer: 2 Rationale 1: An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and is not present with increased peripheral resistance and vasoconstriction. Rationale 2: Increased peripheral resistance causes the blood supply to decrease and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. Rationale 3: Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. Rationale 4: Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance.
The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication? 1. Hemorrhagic shock 2. Hypothermia 3. Sepsis 4. Cardiogenic shock
Correct Answer: 2 Rationale 1: Hemorrhagic shock is caused by a loss of cells or blood volume and is not a result of infusing fluids too quickly. Rationale 2: Hypothermia can result when providing room temperature fluids at a faster pace than the body can warm them. Rationale 3: Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid being administered. Rationale 4: Cardiogenic shock results from poor ventricular functioning, not from the temperature of the intravenous fluids being administered too rapidly.
A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Anaphylactic 4. Obstructive
Correct Answer: 2 Rationale 1: Pulmonary edema would not be present in hypovolemic shock. Rationale 2: In cardiogenic shock, there is a low cardiac output, hypotension, and pulmonary edema. Rationale 3: Pulmonary edema would not be present in anaphylactic shock. Rationale 4: Pulmonary edema would not be present in obstructive shock
Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%
Correct Answer: 2 Rationale 1: The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not reduced. Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. Rationale 3: Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Rationale 4: SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased.
Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringer's lactate (RL) over 15 minutes 3. Two liters of D5W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour
Correct Answer: 2 Rationale 1: This is not an adequate amount of fluid replacement. Rationale 2: The patient requires immediate infusion of an adequate amount of fluid. Fluid resuscitation begins with 500 to 1,000 mL of an isotonic solution. Rationale 3: This is a hypotonic solution and would not help with fluid resuscitation. Rationale 4: This is a hypotonic solution and would not help with fluid resuscitation.
Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema
Correct Answer: 2,3 Rationale 1: Fluid volume overload is not an identified complication of hypovolemic shock. Rationale 2: Renal insufficiency is a serious complication because of the prerenal etiology of hypovolemia. Rationale 3: Early identification and correction of the fluid volume deficit in hypovolemic shock is necessary to prevent cerebral ischemia. Rationale 4: Although physiologic stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Rationale 5: Pulmonary edema is not an identified complication of hypovolemic shock.
What will the nurse identify as symptoms of hypovolemic shock in a patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Temperature of 97.6°F (36.4°C) 2. Restlessness 3. Decrease in blood pressure of 20 mm Hg when the patient sits up 4. Capillary refill time greater than 3 seconds 5. Sinus bradycardia of 55 beats per minute
Correct Answer: 2,3,4 Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status. Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock. Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced. Rationale 5: Bradycardia is not present. The compensatory response is to increase the heart rate to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.
The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output 2. Severe constipation, causing watery diarrhea 3. Ascites 4. Syndrome of inappropriate ADH (SIADH)
Correct Answer: 3 Rationale 1: Although ECG changes reflect the effectiveness of the heart's pumping when circulating the blood, it is not a risk factor for hypovolemic shock, which reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. Rationale 2: Severe constipation does not affect the circulating blood volume. Rationale 3: Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. Rationale 4: Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema.
The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions: 1. Move quickly into the interstitial spaces and can cause third spacing 2. Stay longer to expand the intravascular space but deplete intracellular fluid levels 3. Do not stay in the intravascular space long enough to expand the circulating blood volume 4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low
Correct Answer: 3 Rationale 1: Hypotonic solutions do not cause third spacing. Rationale 2: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume. Rationale 3: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume. Rationale 4: The bore size of the needle does not affect the displacement or shifting of fluids.
A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time? 1. Limit patient movement. 2. Prepare to administer crystalloids. 3. Administer phenylephrine as prescribed. 4. Administer atropine as prescribed.
Correct Answer: 4 Rationale 1: Limiting movement will not correct bradycardia in the patient with neurogenic shock. Rationale 2: Crystalloids are used to correct vasodilation. Rationale 3: Phenylephrine is used in the patient with neurogenic shock to correct hypotension. Rationale 4: Bradycardia in neurogenic shock is corrected by the administration of atropine at the dose of 0.5 to 1.0 mg intravenous every 5 minutes to a total dose of 3 mg.
A patient weighing 220 lbs is prescribed 10 mcg/kg/min of dopamine to improve cardiac output from cardiogenic shock. How many milligrams of dopamine will the patient receive in an hour?
Correct Answer: 60 Rationale : Determine the patient's weight in kg by dividing 220 lbs by 2.2 or 100 kg. Then multiply the number of mcg of medication the patient is to receive per minute by 100 kg or 10 mcg × 100 kg = 1,000 mcg. This is the dosage the patient will receive in 1 minute. To determine the amount of medication in 1 hour, multiply 1,000 mcg × 60 = 60,000 mcg. Using the conversion 1 mg = 1,000 mcg, divide 60,000 mcg by 1,000 mcg to determine that the patient will receive 60 mg of dopamine in 1 hour.
5. When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the a. cardiac output is increased and the central venous pressure (CVP) is low. b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low. c. heart rate is decreased, and the systemic vascular resistance is low. d. cardiac output is decreased and the PAWP is high.
Correct Answer: A Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.
19. While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient's bed is elevated to 75 degrees. This finding indicates a need for a. additional fluid replacement. b. antibiotic administration. c. infusion of a sympathomimetic drug. d. administration of increased oxygen.
Correct Answer: A Rationale: A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions. There are no data to suggest that antibiotics, sympathomimetics, or additional oxygen are needed.
21. A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a. urine output of 0.5 ml/kg/hr. b. decreased peripheral edema. c. decreased CVP. d. oxygen saturation 90% or more.
Correct Answer: A Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.
15. The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a. urine output is 40 ml over the last hour. b. hemoglobin is within normal limits. c. CVP has decreased. d. mean arterial pressure (MAP) is 65 mm Hg.
Correct Answer: A Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.
23. A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a. The cardiac output is elevated. b. The central venous pressure (CVP) is increased. c. The systemic vascular resistance (SVR) is high. d. The PAWP is high.
Correct Answer: A Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.
26. An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes a. respiratory rate of 10 breaths/min. b. fixed urine specific gravity at 1.010. c. MAP of 55 mm Hg. d. 360-ml urine output in 8 hours.
Correct Answer: B Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular necrosis. With MODS, the patient's respiratory rate would initially increase. The MAP of 55 shows continued shock, but not necessarily progression to MODS. A 360-ml urine output over 8 hours indicates adequate renal perfusion.
22. A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first? a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl. b. Give normal saline IV at 500 ml/hr. c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg. d. Infuse drotrecogin- (Xigris) 24 mcg/kg.
Correct Answer: B Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions are also appropriate and should be initiated quickly as well.
17. Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the drug, the nurse ensures that the a. patient's heart rate is less than 100. b. patient has received adequate fluid replacement. c. patient's urine output is within normal range. d. patient is not receiving other sympathomimetic drugs.
Correct Answer: B Rationale: If vasoconstrictors are given in a hypovolemic patient, the peripheral vasoconstriction will further decrease tissue perfusion. A patient with hypovolemia is likely to have a heart rate greater than 100 and a low urine output, so these values are not contraindications to vasoconstrictor therapy. Patients may receive other sympathomimetic drugs concurrently with Levophed.
4. While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a. cold, mottled extremities. b. restlessness and apprehension. c. a heart rate of 120 and cool, clammy skin. d. systolic BP less than 90 mm Hg.
Correct Answer: B Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.
6. A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a. Insert two 14-gauge IV catheters. b. Administer oxygen at 100% per non-rebreather mask. c. Place the patient on continuous cardiac monitor. d. Draw blood to type and crossmatch for transfusions.
Correct Answer: B Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.
11. A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a. Administer all medications through the patient's indwelling central line. b. Place the patient in a private room. c. Restrict the patient to foods that have been well-cooked or processed. d. Insert a nasogastric (NG) tube for enteral feeding.
Correct Answer: B Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.
8. The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include a. pH 7.48, PaCO2 33 mm Hg. b. pH 7.33, PaCO2 30 mm Hg. c. pH 7.41, PaCO2 50 mm Hg. d. pH 7.38, PaCO2 45 mm Hg.
Correct Answer: B Rationale: The patient's low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning "pH 7.48" suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning "pH 7.41" suggest compensated respiratory acidosis. The values in the answer beginning "pH 7.38" are normal.
25. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are a. stool guaiac and bowel sounds. b. lung sounds and oxygenation status. c. serum creatinine and urinary output. d. serum bilirubin levels and skin color.
Correct Answer: B Rationale: The respiratory system is usually the system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.
14. The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. a liter of lactated Ringer's solution. b. 500 ml of 5% albumin. c. two 14-gauge IV catheters. d. a retention catheter.
Correct Answer: C Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient had been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, it is generally accepted that crystalloids should be used as the initial therapy for fluid resuscitation. A catheter would likely be ordered, but in the 1 minute that the nurse has to obtain supplies, the IV catheters would take priority.
18. When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and nitroglycerin (Tridil) infusions, the best evidence that the medications are effective is that the a. systolic BP increases to greater than 100 mm Hg. b. cardiac monitor shows sinus rhythm at 96 beats/min. c. PAWP drops to normal range. d. troponin and creatine kinase levels decrease.
Correct Answer: C Rationale: Because PAWP is increased in cardiogenic shock as a result of the increase in volume and pressure in the left ventricle, normalization of PAWP is the best indicator of patient improvement. The changes in BP and heart rate could occur with dobutamine infusion even if patient tissue perfusion was not improved. Troponin and creatine kinase (CK) levels are indicators of cardiac cellular death and are not used as indicators of improved tissue perfusion.
27. When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a. BP 88/56 mm Hg b. Apical pulse 110 beats/min c. Urine output 15 ml for 2 hours d. Arterial oxygen saturation 90%
Correct Answer: C Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.
24. When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS? a. The patient has crackles throughout both lung fields. b. The patient complains of 8/10 crushing chest pain. c. The patient has an elevated ammonia level and confusion. d. The patient has cool extremities and weak pedal pulses.
Correct Answer: C Rationale: The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure. The crackles, chest pain, and cool extremities are all consistent with cardiogenic shock and do not indicate that there are failures in other major organ systems.
3. A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b. stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.
Correct Answer: C Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.
10. A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. nitroglycerine (Tridil). b. dobutamine (Dobutrex). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
Correct Answer: C Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.
16. The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a. The patient is restless and anxious. b. The patient has a heart rate of 134. c. The patient has hypotonic bowel sounds. d. The patient has a temperature of 94.1° F.
Correct Answer: D Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.
20. The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to a. arrange for the hospital pastoral care staff to visit the patient. b. ask the health care provider to prescribe a sedative drug for the patient. c. leave the patient alone with family members whenever possible. d. place the patient's call bell where it can be easily reached.
Correct Answer: D Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff should be asked to visit only after checking with the patient to determine whether this is desired. Providing time for family to spend with the patient is appropriate, but patients and family should not feel that the nurse is unavailable. Sedative administration is helpful but does not as directly address the patient's anxiety about dying.
2. A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the a. progressive stage of septic shock. b. compensatory stage of diabetic shock. c. refractory stage of cardiogenic shock. d. progressive stage of hypovolemic shock.
Correct Answer: D Rationale: The patient's history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with hypovolemia, and the symptoms are most consistent with the progressive stage of shock. The patient's temperature of 97° F is inconsistent with septic shock. The history is inconsistent with a diagnosis of cardiogenic shock, and the patient's neurologic status is not consistent with refractory shock.
A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of: a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.
Correct answer: b Rationale: Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temperature must be higher than 100.9° F (38.3° C), or the core temperature must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or elevated pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation.
The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.
Correct answer: d Rationale: Adequate tissue perfusion in a patient with multiple-organ dysfunction syndrome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.
Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply): a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload.
Correct answers: a, c Rationale: Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device.
A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the a. progressive stage of septic shock. b. compensatory stage of diabetic shock. c. refractory stage of cardiogenic shock. d. progressive stage of hypovolemic shock.
D
A massive gastrointestinal bleed has resulted in hypovolemic shock in a patient. What is a priority nursing diagnosis? A. Acute pain B. Impaired tissue integrity C. Decreased cardiac output D. Ineffective tissue perfusion
D
The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to a. arrange for the hospital pastoral care staff to visit the patient. b. ask the health care provider to prescribe a sedative drug for the patient. c. leave the patient alone with family members whenever possible. d. place the patient's call bell where it can be easily reached.
D
The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a. The patient is restless and anxious. b. The patient has a heart rate of 134. c. The patient has hypotonic bowel sounds. d. The patient has a temperature of 94.1° F.
D
What laboratory finding fits with a medical diagnosis of cardiogenic shock? A. Decreased liver enzymes B. Increased white blood cells C. Decreased red blood cells, hemoglobin, and hematocrit D. Increased blood urea nitrogen (BUN) and serum creatinine levels
D
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which of the following clinical manifestations of multiple organ dysfunction syndrome (MODS)? A) Increased gastrointestinal (GI) motility B) Increased serum albumin C) Decreased blood urea nitrogen (BUN)/creatinine ratio D) Decreased respiratory compliance
D Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.
A massive gastrointestinal bleed has resulted in hypovolemic shock in an elderly patient. Which of the following is a priority nursing diagnosis? A) Acute pain B) Impaired tissue integrity C) Decreased cardiac output D) Ineffective tissue perfusion
D The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.
A 70-year-old man presents to the emergency department with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate. This patient's condition can best be defined as which of the following? (A) Multi-organ dysfunction syndrome (MODS) (B) Sepsis (C) Septic shock (D) Severe sepsis (E) Systemic inflammatory response syndrome (SIRS)
D) Severe sepsis. The patient fulfills criteria for severe sepsis, defined as sepsis with evidence of organ dysfunction, hypoperfusion, or hypotension. SIRS is defined as an inflammatory response to insult manifested by 2 of the following: temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F), heart rate greater than 90 bpm, respiratory rate greater than 20 breaths/min, and white blood cell count greater that 12 × 103/μL, less than 4 × 103/μL, or 10% bands. A diagnosis of sepsis is given if infec- tion is present in addition to meeting criteria for SIRS. Septic shock includes sepsis-induced hypotension (despite fluid resuscitation) along with evidence of hypoperfusion. MODS is the presence of altered organ function such that hemostasis cannot be maintained without intervention.1 This patient's lack of fluid resuscitation classifies him as having severe sepsis rather than septic shock.
The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a-22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident b-48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c-65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina d-82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection
D- A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.
Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? a- Cardiac index (CI) 5 L/min/m2 b-Central venous pressure 8 mm Hg c-Mean arterial pressure (MAP) 86 mm Hg d-Pulmonary artery pressure (PAP) 28/14 mm Hg
D- Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be due to the MI. The CI, CVP, and MAP readings are normal.
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a-Acute pain b-Impaired tissue integrity c-Decreased cardiac output d-Ineffective tissue perfusion
D- The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.
What laboratory finding fits with a medical diagnosis of cardiogenic shock? a-Decreased liver enzymes b-Increased white blood cells c-Decreased red blood cells, hemoglobin, and hematocrit d-Increased blood urea nitrogen (BUN) and serum creatinine levels
D- The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.
Which of the following is an indication for using corticosteroids in septic shock? (A) Acute respiratory distress syndrome (ARDS) (B) Necrotizing pneumonia (C) Peritonitis (D) Sepsis responding well to fluid resuscitation (E) Vasopressor-dependent septic shock
E) Vasopressor-dependent septic shock. An inappropriate cortisol response is not uncommon in patients with septic shock. Low-dose IV corticosteroids (hydrocortisone 200-300 mg/day) are recommended
p. 825, Patient-Centered Care; Evidence-Based Practice The patient is an 82-year-old woman who has been a resident in an extended-care facility for the past year because of poor mobility and self-care problems. Today she is brought to the emergency department because she does not recognize her son and does not know where she is. She completed drug therapy for a urinary tract infection 1 week ago. Her skin is thin, and she has many bruises. In addition, she has a healing wound on her left shin, which her son tells you occurred 3 days ago when she scraped the area trying to get out of bed alone. The skin immediately surrounding the wound appears normal; however, about 3 inches to the right of the wound the skin is red, firm, and warm to the touch. These are her vital signs: T, 100.8 F (38.2 C); P, 112 beats/min; R, 24 breaths/min; BP, 118/80; SpO2, 92%. Oxygen at 3 L/min is applied until the neurologist can evaluate her, and an IV with normal saline is started at 100 mL/hr. Her son is concerned because she was given her oral antidiabetic drug this morning (5 hours ago) but has not eaten breakfast or lunch. When you check her blood glucose level, it is 131 mg/dL. When you assess her 15 minutes later, her oxygen saturation is 90%. 1. What risk factors does this patient have for sepsis? 2. What manifestations does she have that are consistent with sepsis and systemic inflammatory response syndrome (SIRS)? 3. What assessment should you perform immediately? 4. What would be the most likely source of infection? 5. Should you express concern about the possibility of sepsis and SIRS to the emergency department intensivist? Why or why not?
Suggested Responses: 1. What risk factors does this patient have for sepsis? Risk factors include older age, diabetes mellitus, poor mobility and self-care problems, a known urinary tract infection within the past 30 days, and an open skin area on a lower extremity. 2. What manifestations does she have that are consistent with sepsis and systemic inflammatory response syndrome (SIRS)? Manifestations include elevated temperature, a heart rate of more than 90 beats/min, a respiratory rate greater than 20 breaths/min, a blood glucose level above 120 mg/dL, a recent known infection, decreasing oxygen saturation, and confusion. 3. What assessment should you perform immediately? Assess the color of her skin and mucous membranes, capillary refill, and capnography. Obtain an order for a serum lactate level and a complete blood count with differential. Also obtain an order to insert a Foley catheter for accurate urine output assessment. 4. What would be the most likely source of infection? The two most likely sources of infection are the leg wound (even though the red area is adjacent to the scrape, it is an indication of cellulitis) and the urinary tract. 5. Should you express concern about the possibility of sepsis and SIRS to the emergency department intensivist? Why or why not? Absolutely; this patient meets multiple criteria for sepsis with SIRS and she is older. Her condition could worsen rapidly to severe sepsis and multiple organ dysfunction syndrome (MODS). She needs immediate intervention to save her life.
A 30-year-old man comes to the emergency department because of increasing pain in the left upper abdominal quadrant. Several hours ago, he was hit hard in that area during a tackle by the head of a football player who was wearing a helmet. He has no other health problems, and the only drug he takes on a regular basis is 325 mg of aspirin daily. These are his vital signs: pulse, 102; respirations, 22; blood pressure, 110/86; oxygen saturation, 96%. He has not eaten since he was hit but did drink a bottle of water on the way to the hospital because he was thirsty. When you examine his abdomen, bruising is present in the left upper quadrant and extends down his left side. 1. Where else should you look for evidence of bleeding? 2. What manifestations of shock are present? 3. How would you classify this stage of shock? Provide a rationale for your evaluation. 4. What additional information should you obtain? 5. What vital sign(s) should you monitor most closely?
Suggested Responses: 1. Where else should you look for evidence of bleeding? His left kidney could have been jarred with this injury even though the blow occurred to the abdomen rather than the back (the kidney is located on the posterior abdominal wall). Check any urine for gross or occult blood. If he has been lying down, blood released as a result of internal bleeding could pool in the posterior area as a result of gravity. Therefore check his lower back area. 2. What manifestations of shock are present? The patient has a rapid pulse, narrowed pulse pressure, oxygen saturation below 98% (he is young and, with no other health problems, should have an oxygen saturation of 98% or higher), and he is thirsty. 3. How would you classify this stage of shock? Provide a rationale for your evaluation. He is most likely in the nonprogressive stage of shock. He is thirsty, indicating that hormonal compensatory mechanisms have started. In addition, his oxygen saturation is lower than normal for his age and health. Because his usual blood pressure is unknown, the shock stage cannot be established on that basis. 4. What additional information should you obtain? Ask the patient if he knows his usual blood pressure. If he has been to this hospital system before, this information might be available in his electronic medical record. Ask when he last urinated and how much. If he is able to urinate, measure the amount and check for blood. If he cannot urinate, scan his bladder to determine whether he has produced any urine. Assess nail beds and oral mucous membranes for pallor or cyanosis. Also check capillary refill. Determine whether he can take a deep breath. He was hit in the upper quadrant, and it is possible that a rib could be fractured. He should have blood drawn for a hematocrit (and possibly hemoglobin) level, although this must be requested by the health care provider. 5. What vital sign(s) should you monitor most closely? Closely monitor the patient's heart rate, pulse oximetry, urine output, blood pressure, and level of consciousness.
Nursing assessment of a client receiving serum albumin for treatment of shock should include: a.) Assessing lung sounds. b.) Monitoring glucose. c.) Monitoring the potassium level. d.) Monitoring hemoglobin and hematocrit.
a.) Assessing lung sounds. Rationale: Colloids pull fluid into vascular space. Circulatory overload could occur. The nurse should assess the client for symptoms of heart failure.
A client in shock is prescribed an inotropic drug to act on alpha and beta receptors. The nurse will most likely be administering: a.) Dopamine. b.) Dobutamine. c.) Pavulon. d.) Milrinone.
a.) Dopamine.
A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock? a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Distributive
a.) Hypovolemic
Which type of fluid is most appropriate for volume replacement for a patient with non-hemorrhagic hypovolemic shock? a.) Lactated Ringers (LR) b.) 10% Dextrose in Water (D 10 W) c.) One-half Normal Saline (1/2% NS) d.) Packed Red Blood Cells (PRBC)
a.) Lactated Ringers (LR)
The client experiences shock following a spinal cord injury. This type of shock is classified as: a.) Hypovolemic. b.) Neurogenic. c.) Cardiogenic. d.) Anaphylactic.
a.) Neurogenic.
A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client: Select all that apply: a.) Rapid shallow respirations. b.) Severe hypotension. c.) Mental status changes. d.) Elevated temperature. e.) Lactic acidosis. f.) Oliguria.
a.) Rapid shallow respirations. d.) Elevated temperature.
The client in shock is prescribed an infusion of lactated Ringer's solution. The nurse recognizes that the function of this fluid in the treatment of shock is to: a.) Replace fluid, and promote urine output. b.) Draw water into cells. c.) Draw water from cells to blood vessels. d.) Maintain vascular volume.
a.) Replace fluid, and promote urine output.
A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a.) The cardiac output is elevated. b.) The central venous pressure (CVP) is increased. c.) The systemic vascular resistance (SVR) is high. d.) The PAWP is high.
a.) The cardiac output is elevated. Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.
A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate: a.) administration of furosemide (Lasix) IV. b.) titration of an epinephrine (Adrenalin) drip. c.) administration of a normal saline bolus. d.) assisting with endotracheal intubation.
a.) administration of furosemide (Lasix) IV. Rationale: The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase myocardial oxygen demand and might extend the MI. The PAWP is already elevated, so normal saline boluses would be contraindicated. There is no indication that the patient requires endotracheal intubation.
When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the a.) cardiac output is increased and the central venous pressure (CVP) is low. b.) pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low. c.) heart rate is decreased, and the systemic vascular resistance is low. d.) cardiac output is decreased and the PAWP is high.
a.) cardiac output is increased and the central venous pressure (CVP) is low. Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.
The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a.) urine output is 40 ml over the last hour. b.) hemoglobin is within normal limits. c.) CVP has decreased. d.) mean arterial pressure (MAP) is 65 mm Hg.
a.) urine output is 40 ml over the last hour. Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.
A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a.) urine output of 0.5 ml/kg/hr. b.) decreased peripheral edema. c.) decreased CVP. d.) oxygen saturation 90% or more.
a.) urine output of 0.5 ml/kg/hr. Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.
An intensive care nurse, is assessing a patient with suspected sepsis. Which predisposing factors would expect to be found in the patient with septic shock? a.) A 45 year old client with a history of renal insufficiency. b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection. c.) A 27 year old with pyelonephritis responding to treatment with an antibiotic. d.) A 50 year old with community acquired tuberculosis.
b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection.
A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a.) Insert two 14-gauge IV catheters. b.) Administer oxygen at 100% per non-rebreather mask. c.) Place the patient on continuous cardiac monitor. d.) Draw blood to type and crossmatch for transfusions.
b.) Administer oxygen at 100% per non-rebreather mask. Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.
The acute care nurse is planning an inservice to present evidence based practices to address the increasing incidence in ventilator associated pneumonia. Interventions included in this protocol include: a.) Avoid the use of agents that increase the pH of the stomach as these blocks their antibacterial properties. b.) Maintaining the head of the bed at 30 degrees and strict hand washing before and after any patient contact. c.) Changing the ventilator circuit at least every 24 hours. d.) Provide routine oral care with a combination of alcohol based products.
b.) Maintaining the head of the bed at 30 degrees and strict hand washing before and after any patient contact.
Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: a.) Monitoring for fluid overload. b.) Monitoring for cardiac dysrhythmias. c.) Monitoring respiratory status. d.) Monitoring for hypotension.
b.) Monitoring for cardiac dysrhythmias. Rationale: Dobutamine is beneficial in cases where shock is caused by heart failure. The drug increases contractility, and has the potential to cause dysrhythmias.
A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a.) Administer all medications through the patient's indwelling central line. b.) Place the patient in a private room. c.) Restrict the patient to foods that have been well-cooked or processed. d.) Insert a nasogastric (NG) tube for enteral feeding.
b.) Place the patient in a private room. Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.
To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are a.) stool guaiac and bowel sounds. b.) lung sounds and oxygenation status. c.) serum creatinine and urinary output. d.) serum bilirubin levels and skin color.
b.) lung sounds and oxygenation status. Rationale: The respiratory system is usually the FIRST system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a.) check the blood pressure. b.) obtain an oxygen saturation. c.) attach a cardiac monitor. d.) check level of consciousness.
b.) obtain an oxygen saturation. Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.
The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include: a.) pH 7.48, PaCO2 33 mm Hg. b.) pH 7.33, PaCO2 30 mm Hg. c.) pH 7.41, PaCO2 50 mm Hg. d.) pH 7.38, PaCO2 45 mm Hg.
b.) pH 7.33, PaCO2 30 mm Hg. Rationale: The patient's low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning "pH 7.48" suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning "pH 7.41" suggest compensated respiratory acidosis. The values in the answer beginning "pH 7.38" are normal.
While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a.) cold, mottled extremities. b.) restlessness and apprehension. c.) a heart rate of 120 and cool, clammy skin. d.) systolic BP less than 90 mm Hg.
b.) restlessness and apprehension. Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.
The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain a.) a liter of lactated Ringer's solution. b.) 500 ml of 5% albumin. c. ) two 14-gauge IV catheters. d.) a retention catheter.
c. ) two 14-gauge IV catheters. Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient had been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, it is generally accepted that crystalloids should be used as the initial therapy for fluid resuscitation. A catheter would likely be ordered, but in the 1 minute that the nurse has to obtain supplies, the IV catheters would take priority.
A client is progressing into the third stage of shock. The nurse will expect this client to demonstrate: Choose all that apply: a.) Intractable circulatory failure. b.) Neuroendocrine responses. c.) Demonstrating MODS. d.) Buildup of metabolic wastes. e.) Profound hypotension. f.) Increase in lactic acidosis.
c.) Demonstrating MODS. d.) Buildup of metabolic wastes.
A 4.5 kg infant is admitted to the pediatric intensive care unit after 33 days of watery diarrhea. The infant is diagnosed with severe dehydration. The infant's skin is mottled and turgor is poor. Capillary refill is delayed, and there is an absence of tears with crying. Which intervention should be the priority action by the healthcare provider? a.) Calculate the mean arterial pressure b.) Draw blood for a complete blood count c.) Establish vascular access d.) Take a complete set of vital signs
c.) Establish vascular access Rationale: Vascular access should be established quickly in order to replace lost volume before shock progresses.
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a.) Antibiotics to treat the underlying infection. b.) Corticosteroids to reduce inflammation. c.) IV fluids to increase intravascular volume. d.) Vasopressors to increase blood pressure.
c.) IV fluids to increase intravascular volume. Rationale: Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage.
When performing a physical assessment of a patient with severe sepsis, what abnormal assessment would the nurse expect to find? a.) A WBC of 8,100 despite the presence of chills. b.) A blood pressure of 100/72 with a capillary refill of <3 seconds. c.) Leucocytosis in a patient with absent bowel sounds. d.) Renal output that fluctuates according to intravenous intake.
c.) Leucocytosis in a patient with absent bowel sounds. Rationale: Leucocytosis in a patient with absent bowel sounds A white count > 12,000/mm3 and a left shift is one of the diagnostic criteria. Absent bowel sounds indicate a possible ileus. This would allow translocation of the intestinal flora into the bloodstream.
A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? a.) Distributive b.) Neurogenic c.) Obstructive d.) Cardiogenic
c.) Obstructive Rationale: Obstructive shock can be caused by anything that impedes the heart's ability to contract and pump blood around the body, as with cardiac tamponade.
Which of the following assessment findings is an early indication of hypovolemic shock? a.) Diminished bowel sounds b.) Increased urinary output c.) Tachycardia d.) Hypertension
c.) Tachycardia Rationale: Tachycardia is an early symptom as the body compensates for a declining blood pressure the heart rate increases to circulate the blood faster to prevent tissue hypoxia.
Multiple organ dysfunction syndrome (MODS) develops in severe sepsis as a result of systemic inflammatory response syndrome (SIRS), disseminated intravascular coagulation and damage to the endothelium. Which of the following statements best describes the management of MODS? a.) The use of proton pump inhibitors and H2 agents to increase the pH of the stomach inhibit the development of stress ulcers, an ileus and malabsorption issues. b.) Maintaining ventilator settings that ensure a tidal volume of at least 6 mL/kg of body weight will keep the lungs from being injured by endothelial damage. c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s). d.) Much of the organ damage that occurs with MODS in the setting of severe sepsis is associated with pre-existing conditions.
c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s).
Sepsis is the most common cause of disseminated intravascular coagulation (DIC). All of the following statements concerning this life threatening complications are true except: a.) The rapidity of onset is determined by the intensity of the trigger and is related to the condition of the patient's liver, bone marrow and endothelium. b.) In the early phase, the patient may demonstrate manifestations of thrombosis and microemboli. c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock. d.) The most critical intervention for DIC is the early identification and treatment of the underlying disorder.
c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock.
When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a.) BP 88/56 mm Hg b.) Apical pulse 110 beats/min c.) Urine output 15 ml for 2 hours d.) Arterial oxygen saturation 90%
c.) Urine output 15 ml for 2 hours Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.
A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a.) cool, clammy skin. b.) shortness of breath. c.) heart rate of 48 beats/min d.) BP of 82/40 mm Hg.
c.) heart rate of 48 beats/min Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.
A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a.) nitroglycerine (Tridil). b.) dobutamine (Dobutrex). c.) norepinephrine (Levophed). d.) sodium nitroprusside (Nipride).
c.) norepinephrine (Levophed). Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.
A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a.) activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b.) stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d.) movement of interstitial fluid to the intravascular space, increasing renal blood flow.
c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.
A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation.
d Rationale: Neurogenic shock results in massive vasodilation without compensation as a result of the loss of sympathetic nervous system vasoconstrictor tone. Massive vasodilation leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and, ultimately, impaired cellular metabolism. Clinical manifestations of neurogenic shock are hypotension (from the massive vasodilation) and bradycardia (from unopposed parasympathetic stimulation).
When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize? a.) Intensity of peripheral pulses and body temperature. b.) Peripheral pulses and heart rate (HR). c.) Metabolic alkalosis and oxygen saturation. d.) Cardiac output (CO) and blood pressure (BP).
d.) Cardiac output (CO) and blood pressure (BP).
The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? a.) Slow the IV infusion rate b.) Administer dopamine c.) No interventions are needed at this time d.) Increase the IV infusion rate
d.) Increase the IV infusion rate
The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a.) The patient is restless and anxious. b.) The patient has a heart rate of 134. c.) The patient has hypotonic bowel sounds. d.) The patient has a temperature of 94.1° F.
d.) The patient has a temperature of 94.1° F. Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.
