When caring for a patient in acute septic shock, the nurse would anticipate
A) Administering osmotic and/or loop diuretics.
B) Infusing large amounts of intravenous fluids.
C) Administering intravenous diphenhydramine (Benadryl).
D) Assisting with insertion of a ventricular assist device (VAD).
Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of intravenous 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.
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which of the following clinical manifestations of multiple organ dysfunction syndrome (MODS)?
A) Increased gastrointestinal (GI) motility
B) Increased serum albumin
C) Decreased blood urea nitrogen (BUN)/creatinine ratio
D) Decreased respiratory compliance
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.
A massive gastrointestinal bleed has resulted in hypovolemic shock in an elderly patient. Which of the following is a priority nursing diagnosis?
A) Acute pain
B) Impaired tissue integrity
C) Decreased cardiac output
D) Ineffective tissue perfusion
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.
Which of the following laboratory findings fits with a diagnosis of cardiogenic shock?
A) Decreased liver enzymes
B) Increased white blood cells
C) Increased blood urea nitrogen and creatinine levels
D) Decreased red blood cells, hemoglobin, and hematocrit
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 red blood cell indices are typically normal because of relative hypovolemia. White blood cell levels do not typically rise in cardiogenic shock.
A patient's localized infection has progressed to the point where septic shock is now suspected. Which of the following is an appropriate treatment modality for this patient?
A) Insulin infusion
B) Aggressive fluid resuscitation
C) Intravenous administration of epinephrine
D) Administration of nitrates and β-adrenergic blockers
Patients in septic shock require large amounts of fluid replacement. Nitrates and β-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).
The nurse would recognize which of the following clinical manifestations as suggestive of sepsis?
A) Respiratory rate of seven breaths per minute
B) Hyperglycemia in the absence of diabetes
C) Sudden diuresis unrelated to drug therapy
D) Bradycardia with sudden increase in blood pressure
Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachycardia and tachypnea.
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
a. check the blood pressure.
b. obtain an oxygen saturation.
c. attach a cardiac monitor.
d. check level of consciousness.
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 97° F (36.1° 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.
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.
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.
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.
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.
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.
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).
B AND C
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.
All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who develops severe respiratory distress and faintness. Which one will the nurse administer first?
a. Epinephrine (Adrenalin)
b. Normal saline infusion
c. Dexamethasone (Decadron)
d. Diphenhydramine (Benadryl)
A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate
a. administration of furosemide (Lasix) IV.
b. titration of an epinephrine (Adrenalin) drip.
c. administration of a normal saline bolus.
d. assisting with endotracheal intubation.
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.
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.
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 94.1° F.
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.
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.
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.
The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to
a. arrange for the hospital pastoral care staff to visit the patient.
b. ask the health care provider to prescribe a sedative drug for the patient.
c. leave the patient alone with family members whenever possible.
d. place the patient's call bell where it can be easily reached.
A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is
a. urine output of 0.5 ml/kg/hr.
b. decreased peripheral edema.
c. decreased CVP.
d. oxygen saturation 90% or more.
A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first?
a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl.
b. Give normal saline IV at 500 ml/hr.
c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg.
d. Infuse drotrecogin- (Xigris) 24 mcg/kg.
A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock?
a. The cardiac output is elevated.
b. The central venous pressure (CVP) is increased.
c. The systemic vascular resistance (SVR) is high.
d. The PAWP is high.
When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS?
a. The patient has crackles throughout both lung fields.
b. The patient complains of 8/10 crushing chest pain.
c. The patient has an elevated ammonia level and confusion.
d. The patient has cool extremities and weak pedal pulses.
To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are
a. stool guaiac and bowel sounds.
b. lung sounds and oxygenation status.
c. serum creatinine and urinary output.
d. serum bilirubin levels and skin color.