Shock NCLEX questions

A pt with toxic shock has received ceftriaxone sodium (Rocephin), 1 g every 12 hours. In addition to culture and sensitivity studies, which other lab findings should the nurse monitor a. Arterial blood gases b. Serum creatinine c. Spinal fluid analysis d. Serum osmolarity

B nurse monitors the blood levels of antibiotics, WBC, serum creatinine and blood urea nitrogen because of the decreased perfusion to the kidneys, which are responsible for filtering out the Rocephin. It is likely that the clearance of the antibiotic has been decreased enough to cause toxicity.

When assessing a patient for EARLY septic shock, the nurse should evaluate the patient for which of the following? a. Hemorrhage b. Cool, clammy skin c. Warm, flushed skin d. Increased blood pressure

C Warm, flushed skin from high cardiac output with vasodilation occurs in warm shock or first phase of septic shock. S&S of early septic shock include fever with restlessness and confusion; normal or decreased BP with tachypnea and tachycardia; increased or normal urine output; nausea, vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock,

Which nursing action is most important in preventing septic shock? a. Getting vital signs every 4 hours for all clients b. Monitoring RBC counts for elevation c. Keeping asepsis of indwelling urinary catheters d. Administer IV fluid replacement therapy as prescribed

C keeping asepsis of indwelling urinary catheters is vital to prevent infection.

The patient who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug has the desired effect, the nurse should assess the client for: a. Increased renal and mesenteric blood flow b. Vasoconstriction c. Decreased preload and afterload d. Increased cardiac output

D At medium doses (4 - 8 mcg/kg/min), dopamine hydrochloride slightly increases the heart rate and improves contractility to increase cardiac output and improve tissue perfusion. When given at low doses (0.5-3), dopamine increases renal and mesenteric blood flow. At high doses (8-10) dopamine produces vasoconstriction, which is undesirable. Dopamine is not given to affect preload and afterload.

Pt who has been taking warfarin has been admitted with severe acute racial bleeding and the following lab results: INR 8; hemoglobin 11; and Hct 33%. In which order should nurse implement the following health care prescriptions? a. Give 1 unit of fresh frozen plasma (FFP) b. Administer vitamin K 2.5 mg by mouth c. Schedule pt for sigmoidoscopy d. Administer IV dextrose 5% in 0.45% NS

D, A, B, C