Nursing Management: Shock & MODS (NCLEX) – Flashcards

1.Correct Answer: B 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.

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.

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.

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.

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.

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.

Correct Answer: C 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.

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.

Correct Answer: C Rationale: The coldness and pallor at the infusion site suggest extravasation of the Neo-Synephrine. 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 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 indicates that the patient is in early neurogenic shock.

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.

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.

Correct Answer: A Rationale: 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 are also appropriate but would not be the first ones administered.

Correct Answer: A 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.