Question 1

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.

Accepted Answer

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.

Question 2

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)

Accepted Answer

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.

Question 3

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

Accepted Answer

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.

Question 4

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?

Accepted Answer

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.

Question 5

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?

Accepted Answer

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.

Question 6

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.

Accepted Answer

ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.

Question 7

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.

Accepted Answer

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.

Question 8

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 101.2Â° F (38.4Â° C)

Accepted Answer

ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Question 9

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.

Accepted Answer

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.

Question 10

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).

Accepted Answer

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.

Question 11

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.

Accepted Answer

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.

Question 12

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).

Accepted Answer

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.

Question 13

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.

Accepted Answer

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.

Question 14

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.

Accepted Answer

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.

Question 15

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.

Accepted Answer

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.

Question 16

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.

Accepted Answer

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.

Question 17

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.

Accepted Answer

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.

Question 18

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

Accepted Answer

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.

Question 19

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.

Accepted Answer

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.

Question 20

15. A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104Â° 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.

Accepted Answer

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.

Question 21

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 68Â° F for a patient with neurogenic shock d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR

Accepted Answer

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.

Question 22

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%

Accepted Answer

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.

Question 23

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.

Accepted Answer

ANS: A The initial actions of the nurse are focused on the ABCsâairway, breathing, circulationâand administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.

Question 24

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

Accepted Answer

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.

Question 25

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

Accepted Answer

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.

Question 26

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.

Accepted Answer

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.

Question 27

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)

Accepted Answer

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.

Question 28

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.

Accepted Answer

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.

Question 29

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.

Accepted Answer

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.

Question 30

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%.

Accepted Answer

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.

Question 31

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.

Accepted Answer

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).

Question 32

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)

Accepted Answer

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.

Question 33

A 78-year-old man has confusion and temperature of 104Â° F (40Â° 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.

Accepted Answer

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 100.9Â° F (38.3Â° C), or the core temperature must be lower than 97.0Â° F (36Â° 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.

Question 34

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.

Accepted Answer

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.

Question 35

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.

Accepted Answer

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.

Question 36

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

Accepted Answer

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.

Question 37

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

Accepted Answer

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.

Question 38

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

Accepted Answer

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.

Question 39

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 Î²-adrenergic blockers

Accepted Answer

C- Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and Î²-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).

Question 40

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

Accepted Answer

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.

Question 41

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

Accepted Answer

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.

Question 42

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

Accepted Answer

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.

Question 43

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 97.2Â° F (36.2Â° 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.

Accepted Answer

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.

Question 44

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.

Accepted Answer

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.

Question 45

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

Accepted Answer

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.

Question 46

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.

Accepted Answer

C

Question 47

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)

Accepted Answer

A

Question 48

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

Accepted Answer

D

Question 49

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

Accepted Answer

D

Question 50

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

Accepted Answer

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.

Question 51

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 97Â° F (36.1Â° 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.

Accepted Answer

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 97Â° 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.

Question 52

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.

Accepted Answer

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.

Question 53

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.

Accepted Answer

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.

Question 54

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.

Accepted Answer

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.

Question 55

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.

Accepted Answer

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.

Question 56

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.

Accepted Answer

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.

Question 57

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).

Accepted Answer

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.

Question 58

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.

Accepted Answer

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.

Question 59

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.

Accepted Answer

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.

Question 60

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.

Accepted Answer

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.

Question 61

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 94.1Â° F.

Accepted Answer

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.

Question 62

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.

Accepted Answer

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.

Question 63

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.

Accepted Answer

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.

Question 64

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.

Accepted Answer

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.

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