Sole- Ch 12 E Questions

After receiving 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 last hour. Given this report, the nurse obtains orders for treatment that include which of the following? (SATA) A. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mmHg B. Increase supplemental oxygen therapy to 60% Venturi mask C. Administer 40 mg furosemide (Lasix) intravenously 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 >101F

A. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mmHg, D. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101F

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy? A. Central venous pressure >/= 8 mmHg B. Heart rate >60 beats/min C. Mean arterial pressure >/= 50 mmHg D. Serum lactate level >6 mEq/L

A. Central venous pressure >/= 8 mmHg

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective? A. Lactated Ringer's should not be infused if lactic acidosis is severe B. 3 mL of crystalloid is administered to replace 10 mL of blood loss C. Administration of colloids is preferred over crystalloids D. Solutions of 0.45% normal saline are used routinely in shock

A. Lactated Ringer's should not be infused if lactic acidosis is severe

Which hemodynamic values should the nurse anticipate in a patient who is in the initial stages of septic shock state? A. Low heart rate; high blood pressure B. High heart rate; low right atrial pressure C. High PAOP; low cardiac output D. High SVR; normal blood pressure

B. High heart rate; low right atrial pressure

The nurse is caring for a patient in shock. Which is a priority action by the nurse? A. Ensure adequate cellular hydration B. Maintain adequate tissue perfusion C. Prevent third-spacing of fluids D. Support mechanical ventilation

B. Maintain adequate tissue perfusion

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart? A. Dopamine (Intropin) B. Phenylephrine (Neo-Synephrine) C. Dobutamine (Dobutrex) D. Nitroprusside (Nipride)

C. Dobutamine (Dobutrex)

The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order? (SATA) A. 5% dextrose B. Albumin C. Lactated Ringer's (LR) D. Normal saline

C. Lactated Ringer's (LR), D. Normal saline

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for? A. Acute respiratory distress syndrome (ARDS) B. Disseminated intravascular coagulation (DIC) C. Increased cerebral perfusion pressure D. Multisystem organ failure and/or dysfunction

D. Multisystem organ failure and/or dysfunction

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? A. Tachycardia B. Hypertension C. Hypoventilation D. Vasodilation

D. Vasodilation

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? A. Blood loss and actual hypovolemia B. Decreased cardiac output C. Third-spacing of fluids into peritoneal space D. Vasodilation and relative hypovolemia

D. Vasodilation and relative hypovolemia