Question 1

The nurse would be most alert for assessment findings of hypovolemic shock in which patient?

Accepted Answer

A patient 6 hours postmastectomy is at risk for hypovolemic shock due to blood loss from the surgical procedure. The other patients listed are not necessarily at immediate risk for hypovolemic shock based on the given information.

Question 2

The nurse anticipates assisting with which therapy to achieve improved outcomes for a patient who is in septic shock?

Accepted Answer

In septic shock, mechanical ventilation with low tidal volumes (4 to 6 ml/kg) is recommended to prevent lung injury and improve outcomes.

Question 3

The nurse would identify which patients as being at increased risk for development of sepsis and septic shock?. Select all that apply.

Accepted Answer

A,C,E

Question 4

The nurse is caring for a patient with endocarditis who is receiving penicillin. The nurse should be particularly attentive to recognize early symptoms of which type of shock?

Accepted Answer

Patients receiving penicillin are at risk for anaphylactic shock, which is a potentially life-threatening allergic reaction. Nurses should be attentive to early symptoms such as rash, itching, swelling, and difficulty breathing, and be prepared to intervene appropriately.

Question 5

The nurse is caring for a patient with papillary muscle rupture. The nurse would be most alert to the development of which type of shock?

Accepted Answer

Papillary muscle rupture is a serious complication of myocardial infarction that can lead to cardiogenic shock, as it compromises the ability of the heart to pump effectively. Septic shock is caused by a bacterial infection, anaphylactic shock by a severe allergic reaction, and neurogenic shock by damage to the spinal cord or brain.

Question 6

A patient has MODS secondary to severe sepsis. The nurse would prioritize interventions to address which finding in this patient?

Accepted Answer

pO₂ refers to the patient's oxygen saturation levels, and in this case, the low value of 54 mmHg indicates poor tissue perfusion and respiratory distress, which are critical issues in MODS. The nurse should prioritize interventions to improve oxygenation and address the underlying cause of the low saturation levels. The other options are also important to address, but they are not as immediately life-threatening as poor oxygenation.

Question 7

A patient admitted to the emergency department after a traumatic injury is becoming more and more lethargic and hard to arouse. Periods of apnea are increasing. To protect the patient's airway, the nurse should prepare to assist with which intervention?

Accepted Answer

Intubation is necessary to protect the patient's airway if they are becoming lethargic and experiencing apnea. Monitoring oxygen saturation and assessing breath sounds may be helpful in determining the patient's respiratory status, but they do not address the immediate concern of protecting the airway. Asking the patient about difficulty breathing may not be effective if they are already becoming lethargic and unresponsive.

Question 8

The nurse is caring for a patient with septic shock and MODS. A family member tearfully tells the nurse, "The doctor said my mother's organs are shutting down. How did that happen?" What is the nurse's best response?

Accepted Answer

During septic shock, inflammation causes vasodilation and increased vascular permeability, leading to hypotension and decreased perfusion to organs. This deprivation of oxygen to organs can cause them to fail. Multi-organ dysfunction syndrome (MODS) occurs when several organs begin to fail as a result of the shock and lack of oxygen.

Question 9

An 80-year-old patient is being admitted from a nursing home for treatment of septic shock. Which assessment finding should the nurse investigate as the most likely source of the sepsis?

Accepted Answer

The most likely source of the sepsis in an elderly patient living in a nursing home is an indwelling urinary catheter, as this increases the risk of urinary tract infections which can lead to sepsis. A red, flat rash in the perineal area may indicate a localized infection but is less likely to cause sepsis. Exposure to chemotherapy or scabies is not a common cause of sepsis.

Question 10

The nurse will plan which interventions to reduce metabolic demands in a patient with multiple organ dysfunction syndrome (MODS)?

Accepted Answer

Administering antipyretics for fever helps reduce metabolic demands by lowering the body's temperature, which can decrease the metabolic rate and oxygen consumption.

Question 11

Which statements by the paramedic who brought a patient to the emergency department would indicate correct field treatment of a patient suspected of being in shock?. Select all that apply.

Accepted Answer

The answer of Which statements by the paramedic who brought...

Question 12

According to standard definitions, which patient would the nurse describe as being in septic shock?

Accepted Answer

Septic shock is defined as sepsis with persistent hypotension despite adequate fluid resuscitation, requiring vasopressor support to maintain a mean arterial pressure of 65 mmHg or greater. Option C describes a patient with an infection and persistent hypotension despite fluid resuscitation, indicating septic shock. Option A is describing respiratory failure, which is not the criteria for septic shock. Option B is describing a febrile patient, but no information is given about hypotension or fluid resuscitation. Option D is describing a patient with an elevated white blood cell count and fever, but these do not meet the criteria for septic shock.

Question 13

A patient developed septic shock related to cancer chemotherapy. This morning the nurse assessed a change in the patient's mental status. The nurse's primary concern would focus on which possible etiology for this change?

Accepted Answer

Septic shock can cause decreased tissue oxygenation due to decreased perfusion, leading to impaired mental status. Anxiety about death, metastasis, or chemotherapy are possible concerns, but they are not the primary concern in this case.

Question 14

A patient who was stabbed in the abdomen has received fluid resuscitation of 2 liters over the last hour. Which finding would the nurse evaluate as indicating this intervention has been ineffective?

Accepted Answer

A heart rate of 142 and regular indicates tachycardia, which suggests that the fluid resuscitation has been ineffective in stabilizing the patient's condition, as the heart rate remains elevated, possibly due to ongoing hypovolemia or shock.

Question 15

A patient in shock is receiving norepinephrine by continuous infusion. For which outcome would the nurse monitor to evaluate the effectiveness of this medication?

Accepted Answer

Norepinephrine is a vasoconstrictor medication that is used to increase blood pressure in patients in shock. Therefore, the nurse would monitor the patient's blood pressure to evaluate the effectiveness of the medication. Option A is incorrect as monitoring cardiac enzymes is not related to the medication. Option B is incorrect as a reduced apical heart rate may indicate bradycardia, which is not the desired effect of norepinephrine. Option C is incorrect as norepinephrine is not used to reduce bleeding.

Question 16

Which patients would the nurse identify as being at increased risk for the development of hypovolemic shock?. Select all that apply.

Accepted Answer

Patients with cirrhosis, ascites, and anasarca (C) are at risk due to fluid shifts and potential bleeding. A patient in a car crash (D) may have internal injuries leading to blood loss. A ruptured abdominal aortic aneurysm (E) can cause massive internal bleeding, leading to hypovolemic shock.

Question 17

The nurse would be most alert for assessment findings of obstructive shock in which patients?. Select all that apply.

Accepted Answer

The answer of The nurse would be most alert for...

Question 18

A patient has developed severe cardiogenic shock and is on a mechanical ventilator. The family asks why the patient's hands feel so cold. What is the nurse's best response?

Accepted Answer

Blood vessels constrict in shock, which takes the blood away from hands and feet. This can cause decreased blood flow and coldness in the extremities.

Question 19

The nurse is caring for a patient with MODS secondary to septic shock whose urine output was 10 mL for the last 2 hours. Temperature is 97 degrees, pulse is 124 and thready, and BP is 88/

Accepted Answer

The patient's low urine output and thready pulse suggest hypovolemia, so administering isotonic fluids at a high rate (20 mL/kg/hr) is the priority to increase circulating volume and improve tissue perfusion. Placing the patient on a warming blanket (A) may be helpful to prevent hypothermia but is not the priority at this point. Drawing blood for BUN and creatinine (C) may be important to monitor renal function, but it is not the current priority. Placing the patient in a kinetic bed (D) may be helpful to prevent pressure ulcers or promote mobility, but it is not the priority at this time.

Question 20

A patient who takes a beta adrenergic blocker is at risk of developing shock after an accident. The nurse is aware that the patient's medication use may alter which assessment finding associated with shock?

Accepted Answer

Beta adrenergic blockers work by blocking the effects of epinephrine and norepinephrine, which are hormones that increase heart rate and blood pressure. In the context of shock, tachycardia (rapid heart rate) is a compensatory mechanism to maintain blood pressure. With beta blocker use, this compensatory mechanism is blunted, and the patient may not exhibit tachycardia even in the presence of hypotension, which can delay recognition and treatment of shock.  Declining mental status, cyanosis, and tachypnea are not directly affected by beta blocker use in the context of shock.

Quiz 54: Caring for the Patient With Inflammatory Response, Shock, and Severe Sepsis