SHOCK
1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a. Assess the blood pressure by Doppler. b. Estimate the systolic pressure as 60 mm Hg. c. Obtain an electronic blood pressure monitor. d. Record the blood pressure as not assessable.
A
10. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. Which of the following is the pathophysiologic mechanism that results in septic shock? a. Bacterial toxins lead to vasodilation. b. Increased white blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. An increase of white blood cells leads to decreased red blood cell production and anemia.
A
10. The nurse is caring for a patient with hypovolemic shock who has had 6 units of packed red blood cells. Which of the following values would alert the nurse to a complication related to the administration of blood? A) Potassium level of 6.0 B) Hemoglobin of 13 C) Sodium level of 134 D) pH 7.37
A
11. A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance
A
13. The patient is in hypovolemic shock from traumatic massive blood loss and is tachypneic and tachycardic, with cool, clammy skin and weak and thready pulses. What additional assessment parameter would the nurse be least likely to find during stage one or early compensated shock? A) Hypotension B) Increased urine output C) Estimated blood loss greater than 30% D) Mild altered mental status
A
13. While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system
A
14. A vasoconstrictor used to treat shock is a. adrenaline. b. Nipride. c. Dobutrex. d. adenosine.
A
14. The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? a. The action of the machine will improve blood supply to the damaged heart. b. The machine will beat for the damaged heart with every beat until it heals. c. The machine will help cleanse the blood of impurities that might damage the heart. d. The machine will remain in place until the patient is ready for a heart transplant.
A
15. The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5
A
15. The patient has developed cardiogenic shock and is decompensating. What pattern of hemodynamic alterations does the nurse expect to find? A) High preload, high afterload, low cardiac index, tachycardia B) Low preload, low afterload, high cardiac index, bradycardia C) Low preload, high afterload, high cardiac index, tachycardia D) High preload, low afterload, high cardiac index, tachycardia
A
15. Which of the following clinical manifestations is not suggestive of systemic inflammatory response syndrome (SIRS)? a. Temperature of 37.5 C b. Heart rate of 95 beats/min c. Respiratory rate of 24 breath/min d. White blood cell (WBC) count of 15,000 cells/mm3
A
16. The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patients skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.
A
19. The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101 F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patients plan of care? a. Insertion of an 18-gauge peripheral intravenous line b. Application of cushioned heel protectors c. Implementation of fall precautions d. Implementation of universal precautions
A
21. A leading cause of death in critically ill patients is sepsis and septic shock. What nursing intervention is most directed toward preventing this life-threatening complication? A) Strict adherence to hand hygiene protocols B) Prompt initiation of isolation protocols C) Patient and family preventive teaching D) Sterile technique for care of intravenous sites
A
21. The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a. Blood cultures b. Chest x-ray c. Foley insertion d. Serum electrolytes
A
23. The most common site for sepsis and septic shock is a. the respiratory system. b. the gastrointestinal system. c. the genitourinary system. d. the circulatory system.
A
25. A critically ill patient has developed multiple organ dysfunction syndrome (MODS). What should the nursing goal for management of the patient with impending MODS center on? A) Early normalization of SvO2 and acidbase balance B) Use of intravenous drotrecogin alfa (Xigris) C) Specific organ system support D) General intensive nursing care
A
27. The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central lineassociated bloodstream infection (CLABSI)? a. Documentation of insertion date b. Elevation of the head of the bed c. Assessment for weaning readiness d. Appropriate sedation management
A
3. The nursing measure that can best enhance large volumes of fluid replacement in hypovolemic shock is a. insertion of a large-diameter peripheral intravenous catheter. b. positioning the patient in the Trendelenburg position. c. forcing at least 240 mL of fluid each hour. d. administering intravenous lines under pressure.
A
31. After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5 F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which active physician order first? a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg. b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101 F.
A
4. The main cause of cardiogenic shock is a. an inability of the heart to pump blood forward. b. hypovolemia, resulting in decreased stroke volume. c. disruption of the conduction system when re-entry phenomenon occurs. d. an inability of the heart to respond to inotropic agents.
A
6. With anaphylactic shock, which mechanism results in a decreased cardiac output? a. Peripheral vasodilation b. Increased cardiac output c. Decreased alveolar ventilation d. Fluid retention resulting in congestive heart failure
A
8. The nurse understands that which of the following patients in the hospital is at the greatest risk for cardiogenic shock? A) The 76-year-old male patient with a history of diabetes mellitus and previous myocardial infarction (MI) B) The 42-year-old male who has mitral valve prolapse with a left ventricular ejection fraction of 65% C) The 52-year-old female with a recent small anteroseptal wall MI D) The 84-year-old female with hypertension
A
9. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. A pulmonary artery catheter is placed. Which of the following hemodynamic values would you expect to find? a. Cardiac output of 8 L/min b. Right atrial pressure of 17 mm Hg c. Pulmonary artery wedge pressure of 23 mm Hg d. Systemic vascular resistance of 1100
A
9. The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a. Dobutamine (Dobutrex) b. Furosemide (Lasix) c. Phenylephrine (Neo-Synephrine) d. Sodium nitroprusside (Nipride)
A
2. The nurse is administering an intravenous antibiotic infusion over 30 minutes for a patient with cellulitis of the left lower extremity. The patient states, I am itching all over and am having trouble swallowing. What priority interventions by the nurse are necessary for this patient? Select all that apply. A) Stop the antibiotic infusion. B) Administer subcutaneous epinephrine. C) Administer diphenhydramine (Benadryl) IV. D) Switch to amoxicillin by mouth. E) Administer Ativan for the patients anxiety.
A, B, C
1. The key to treatment of septic shock is finding the cause of the infection. Which of the following cultures are obtained before antibiotic therapy is initiated? (Select all that apply.) a. Blood cultures x 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. CBC with differential
A, B, C, D
2. Which of the following historical findings would indicate a high risk for latex allergy? (Select all that apply.) a. Allergic reaction to anesthetics b. Eczema of the hands c. Congenital urologic disorder d. Asthma e. Health care worker
A, B, C, E
3. A nursing assessment of a patient with hypovolemic shock is most likely to reveal what assessment findings? Select all that apply. A) Tachycardia B) Oliguria C) Disoriented to time and place D) Diuresis E) Bradycardia F) Hypotension
A, B, C, F
9. The patient in the ICU is being treated for left lower lobe pneumonia. What assessment findings by the nurse may indicate that the patient is developing systemic inflammatory response syndrome (SIRS)? Select all that apply. A) White blood cell count of 24,000/mm3 B) Respiratory rate of 24 C) Blood pressure of 100/60 D) Heart rate 96 E) Atrial fibrillation
A, B, D
2. The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output
A, C, F
3. Evidence-based guidelines for the treatment of septic shock include which of the following?(Select all that apply.) a. Fluid resuscitation to maintain central venous pressure at 8 mm Hg or greater b. Low-dose dopamine for renal protection c. High-dose corticosteroids d. Administration of activated protein C e. Achieve central venous oxygen saturation of 70% or more
A, D, E
1. Shock syndrome can best be described as a a. physiologic state resulting in hypotension and tachycardia. b. generalized systemic response to inadequate tissue perfusion. c. degenerative condition leading to death. d. condition occurring with hypovolemia that results in irreversible hypotension.
B
10. Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? a. Diphenhydramine (Benadryl) 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone (Solu-Medrol) 125 mg intravenously d. Ranitidine (Zantac) 50 mg intravenously
B
11. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. The medical management of the patients condition is aimed toward a. limiting fluids to minimize the possibility of congestive heart failure. b. finding and eradicating the cause of infection. c. discontinuing invasive monitoring as a possible cause of sepsis. d. administering vasodilator substances to increase blood flow to vital organs.
B
12. A critically ill patient has developed shock. What nursing assessment result indicates a normal compensatory mechanism? A) Reduction of respiratory depth B) Increase in systemic vascular resistance (SVR) C) Decrease in circulating catecholamines D) Increased stimulation of baroreceptors
B
12. Signs of hypovolemia in the trauma patient include a. distended neck veins. b. a decreased level of consciousness. c. bounding radial and pedal pulses. d. a widening pulse pressure.
B
17. For a patient in cardiogenic shock, the physician has ordered an intravenous continuous infusion of dobutamine hydrochloride. What nursing assessment result demonstrates achievement of therapeutic goals? A) Blood pressure 120/70 mm Hg B) Urine output 30 to 40 mL/hr C) Arterial oxygen saturation 60% D) Heart rate 110 to 120 bpm
B
17. The difference between primary and secondary multiple organ dysfunction syndrome (MODS) is that primary MODS is the result of a. widespread systemic inflammation that results in dysfunction of organs not involved in the initial insult. b. direct organ injury. c. disorganization of the immune system response. d. widespread disruption of the coagulation system.
B
18. The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.
B
2. The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L
B
20. A critically ill patient has developed septic shock. What pattern of hemodynamic values does the nurse expect to find? A) Low preload, high afterload, low cardiac index, tachycardia B) Low preload and afterload, high cardiac index, tachycardia C) High preload and afterload, low cardiac index, tachycardia D) Normal preload, low afterload, normal cardiac index, bradycardia
B
20. A patient is admitted to the intensive care unit after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. DIC is known to occur in patients with retained placental fragments. What is the result of DIC? a. Hypersensitive response to an antigen, resulting in anaphylaxis b. Depletion of clotting factors and excessive fibrinolysis, resulting in simultaneous microvascular clotting and hemorrhage c. Vasodilatation, resulting in hypotension d. Septic shock, resulting in vasodilation and decreased perfusion
B
22. Which medication is not recommended in the treatment of shock-related lactic acidosis? a. Glucose b. Sodium bicarbonate c. Vasoconstrictor d. Large quantity of crystalloids fluids
B
23. A critically ill patient who is mechanically ventilated and has developed shock is in need of nutritional support. What route is preferred for this patient? A) Oral B) Enteral C) Parenteral D) Variable
B
24. Profound weight loss in patients with SIRS or MODS is the result of a. hypometabolism. b. hypermetabolism. c. hyperglycemia. d. intolerance to enteral feedings.
B
24. The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? a. Administer acetaminophen (Tylenol) 650-mg suppository prn every 6 hours for pain. b. Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic. c. Complete neurological assessment every 4 hours for the next 24 hours. d. Administer furosemide (Lasix) 20 mg IV every 4 hours for a CVP > 20 mm Hg.
B
25. The nurse is administering intravenous norepinephrine (Levophed) at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse? a. Blood pressure 100/60 mm Hg b. Swelling at the IV site c. Heart rate of 110 beats/min d. Central venous pressure (CVP) of 8 mm Hg
B
26. The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm-5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a. Furosemide (Lasix) 20 mg intravenous (IV) every 4 hours as needed for CVP > 20 mm Hg b. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain c. Dobutamine (Dobutrex) infusion at a rate of 2-20 mcg/kg/min as needed for CI < 2 L/min/m2 d. Dopamine (Intropin) infusion at a rate of 5-10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg
B
32. The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? a. Blood transfusion with packed red blood cells is required. b. Hemoglobin and hematocrit results indicate hemodilution. c. Fluid resuscitation has resulted in fluid volume overload. d. Fluid resuscitation has resulted in third spacing of fluid.
B
4. The nurse is assigned to the care of a patient in the ICU who is in cardiogenic shock. What priority nursing intervention is necessary to conserve myocardial energy and decrease workload of the heart? A) Lactated Ringers at 150 mL/hr B) Morphine sulfate 4 mg IV C) Furosemide (Lasix) 80 mg IV D) Epinephrine 1:1,000, 0.3 mL IV
B
8. The patients at highest risk for neurogenic shock are those who have had a. a stroke. b. a spinal cord injury. c. Guillain-Barr syndrome. d. a craniotomy.
B
1. Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patients blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102 F. The nurse notes the new onset of hematuria in the patients Foley catheter. What are the priority nursing actions? (Select all that apply.) a. Administer acetaminophen (Tylenol). b. Document the patients response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the physician. f. Stop the transfusion.
B, D, E, F
14. A patient is being treated for severe hypovolemic shock. Based on the primary treatment goal, what nursing intervention has the highest priority? A) Frequent measurement of vital signs B) Management of mechanical ventilation C) Rapid intravenous fluid administration D) Insertion of urinary drainage catheter
C
16. When SIRS is the result of infection, it is called a. inflammation. b. anaphylaxis. c. sepsis. d. pneumonia.
C
17. The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8 F. Which intervention is most important for the nurse to include in the patients plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)
C
18. A patient is in shock and is exhibiting low blood pressure, low systemic vascular resistance (SVR), peripheral edema, pulmonary wheezing, tachycardia, and nausea and vomiting. What precipitating event does the nurse expect for this group of symptoms? A) Acute myocardial infarction B) Bacterial infectious illness C) Recent seafood meal D) Massive fluid loss
C
18. The gastrointestinal system is a common target organ for MODS related to a. anorexia. b. limited or absent food ingestion. c. disruption of the mucosal barrier from hypoperfusion. d. a decrease in hydrochloric acid secretion.
C
19. Clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which symptom below is indicative of hepatic insufficiency? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase
C
2. Hypovolemic shock that results from an internal shifting of fluid from the intravascular space to the extravascular space is known as a. absolute hypovolemia. b. distributive hypovolemia. c. relative hypovolemia. d. compensatory hypovolemia.
C
20. The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6 F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patients heart rate.
C
21. Laboratory values for DIC show abnormalities in a. liver function tests. b. tests for renal function. c. platelet counts. d. blood glucose levels.
C
22. The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patients care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a. Frequent turning b. Monitoring intake and output c. Enteral feedings d. Pain management
C
25. One theory suggests that organ dysfunction in MODS occurs in a sequential or progressive pattern. Place the following organs in the order in which they are affected: 1. Bone marrow 2. Cardiac 3. Gut 4. Kidneys 5. Liver 6. Lungs a. 6, 5, 2, 1, 3, 4 b. 5, 4, 6, 1, 2, 3 c. 6, 5, 3, 4, 2, 1 d. 6, 3, 4, 5, 2, 1
C
29. The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? a. Administer pain medication. b. Turn patient every 2 hours. c. Assess core body temperature. d. Apply bilateral heel protectors.
C
30. The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex). The physicians order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? a. Obtain a stat serum potassium level. b. Order a stat 12-lead electrocardiogram. c. Reduce the rate of dobutamine (Dobutrex). d. Assess the patients hourly urine output.
C
5. A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringers bolus d. Packed red blood cells
C
5. The nurse in the ICU is assigned to care for a patient with septic shock. What nursing interventions are necessary to prevent malnutrition and optimize cellular function in this patient? A) Administration of crystalloid solutions IV B) High calorie, low protein diet C) Enteral feedings D) Administration of multivitamins in the IV fluid
C
6. In developing the discharge plan for a patient who was treated in the hospital for anaphylactic shock related to a nonsteroidal anti-inflammatory (NSAID) allergy, what would be the most important information for the nurse to include? A) Adhere to dietary restrictions. B) Follow up in one month with the physician. C) Check labels of over-the-counter medications prior to taking. D) Have blood pressure checked on a regular basis.
C
7. The nurse is assigned to a patient in the ICU who is on a ventilator for exacerbation of chronic obstructive pulmonary disease. What intervention by the nurse can prevent the development of multiple organ dysfunction syndrome? A) Suctioning the patient every 2 hours B) Enteral feedings C) Oral care every 2 hours D) Administration of total parenteral nutrition
C
8. Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102 F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids
C
1. What would the nurse identify as the primary purpose for the administration of intravenous (IV) crystalloid fluids in the patient with hypovolemic shock? A) Decrease myocardial oxygen demand. B) Maximize oxygen-carrying capability. C) Increase capillary permeability. D) Restore circulating volume.
D
12. During the initial stages of shock, what are the physiological effects of decreased cardiac output? a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation
D
13. Which medications are not effective in the immediate treatment of acute anaphylaxis? a. Epinephrine b. Vasopressors c. Diphenhydramine (Benadryl) IV d. Corticosteroids
D
16. The patient is in decompensated cardiogenic shock. What collaborative intervention best addresses the central cause of cardiogenic shock? A) Mechanical ventilation B) Hemodynamic monitoring C) Pharmacologic sedation D) Intravenous nitrate infusion
D
19. The patient has been diagnosed with shock secondary to an antigenantibody reaction. What collaborative intravenous intervention has the highest priority? A) Dobutamine B) Red blood cells C) Antimicrobials D) Epinephrine
D
22. A patient has been diagnosed with septic shock and is receiving intravenous fluid resuscitation along with other therapies. What nursing assessment best indicates improvement in tissue perfusion? A) Mean arterial pressure 65 to 70 mm Hg B) SvO2 80% to 90% C) Skin warm and dry D) Arterial bicarbonate ion 22 to 24 mEq/L
D
23. The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a. Normal body temperature b. Balanced intake and output c. Adequate pain management d. Urine output of 0.5 mL/kg/hr
D
24. A patient in shock has developed systemic inflammatory response syndrome (SIRS). What is the most likely type of shock resulting in SIRS? A) Hypovolemic B) Septic C) Cardiogenic D) Any shock
D
28. The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18
D
3. The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output
D
4. A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.
D
5. Which of the following hemodynamic parameters supports the diagnosis of cardiogenic shock? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index
D
6. The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output
D
7. The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102 F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures from two sites c. IV antibiotic administration d. Isotonic fluid challenge
D
7. Which of the following drugs promotes bronchodilation and vasoconstriction? a. Solu-Medrol b. Gentamicin c. Atropine d. Epinephrine
D