Deck 67: Nursing Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome

Question 1

A 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 new heart murmurs
B) Decreased troponin level
C) Warm, pink, and dry skin
D) Blood pressure 92/40 mm Hg

Answer 1

Warm, pink, and dry skin

Question 2

Norepinephrine (Levophed)has been prescribed for a patient who was admitted with dehydration and hypotension.Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

A) The patient's central venous pressure is 3 mm Hg.
B) The patient is in sinus tachycardia at 120 beats/min.
C) The patient is receiving low dose dopamine (Intropin).
D) The patient has had no urine output since being admitted.

Answer 2

The patient's central venous pressure is 3 mm Hg.

Question 3

A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED).Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?

A) Inspiratory crackles.
B) Cool, clammy extremities.
C) Apical heart rate 45 beats/min.
D) Temperature 101.2° F (38.4° C).

Answer 3

Apical heart rate 45 beats/min.

Question 4

A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54,pulse 64,and an elevated pulmonary artery wedge pressure.Which collaborative intervention ordered by the health care provider should the nurse question?

A) Infuse normal saline at 250 mL/hr.
B) Keep head of bed elevated to 30 degrees.
C) Hold nitroprusside (Nipride) if systolic BP <90 mm Hg.
D) Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

Question 5

The nurse is 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) Blood pressure (BP) 92/56 mm Hg
B) Skin cool and clammy
C) Oxygen saturation 92%
D) Heart rate 118 beats/minute

Question 6

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

A) Check temperature every 2 hours.
B) Monitor breath sounds frequently.
C) Maintain patient in supine position.
D) Assess skin for flushing and itching.

Question 7

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED)with cool,clammy skin; tachycardia; and hypotension.Which intervention ordered by the health care provider should the nurse implement first?

A) Insert two large-bore IV catheters.
B) Initiate continuous electrocardiogram (ECG) monitoring.
C) Provide oxygen at 100% per non-rebreather mask.
D) Draw blood to type and crossmatch for transfusions.

Question 8

During change-of-shift report,the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days.Which finding is most important for the nurse to report to the health care provider?

A) New onset of confusion
B) Heart rate 112 beats/minute
C) Decreased bowel sounds
D) Pale, cool, and dry extremities

Question 9

A patient with septic shock has a BP of 70/46 mm Hg,pulse 136,respirations 32,temperature 104° F,and blood glucose 246 mg/dL.Which intervention ordered by the health care provider should the nurse implement first?

A) Give normal saline IV at 500 mL/hr.
B) Give acetaminophen (Tylenol) 650 mg rectally.
C) Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
D) Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

Question 10

When the nurse educator is evaluating the skills of a new registered nurse (RN)caring for patients experiencing shock,which action by the new RN indicates a need for more education?

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) Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
D) Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock

Question 11

After receiving 2 L 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 an order for

A) nitroglycerine (Tridil).
B) norepinephrine (Levophed).
C) sodium nitroprusside (Nipride).
D) methylprednisolone (Solu-Medrol).

Question 12

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?

A) Heart rate
B) Orientation
C) Blood pressure
D) Oxygen saturation

Question 13

Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective?

A) Hemoglobin is within normal limits.
B) Urine output is 60 mL over the last hour.
C) Central venous pressure (CVP) is normal.
D) Mean arterial pressure (MAP) is 72 mm Hg.

Question 14

A patient with cardiogenic shock has the following vital signs: BP 102/50,pulse 128,respirations 28.The pulmonary artery wedge pressure (PAWP)is increased and cardiac output is low.The nurse will anticipate an order for which medication?

A) 5% human albumin
B) Furosemide (Lasix) IV
C) Epinephrine (Adrenalin) drip
D) Hydrocortisone (Solu-Cortef)

Question 15

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR).Which intervention should the nurse anticipate doing next?

A) Increase the rate for the dopamine (Intropin) infusion.
B) Decrease the rate for the nitroglycerin (Tridil) infusion.
C) Increase the rate for the sodium nitroprusside (Nipride) infusion.
D) Decrease the rate for the 5% dextrose in normal saline (D₅/.9 NS) infusion.

Question 16

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate 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's extremities are cool and pulses are weak.
D) The patient has bilateral crackles throughout lung fields.

Question 17

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours.The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low.Which order by the health care provider will the nurse question?

A) Give PRN furosemide (Lasix) 40 mg IV.
B) Increase normal saline infusion to 250 mL/hr.
C) Administer hydrocortisone (Solu-Cortef) 100 mg IV.
D) Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

Question 18

To evaluate the effectiveness of the pantoprazole (Protonix)ordered for a patient with systemic inflammatory response syndrome (SIRS),which assessment will the nurse perform?

A) Auscultate bowel sounds.
B) Palpate for abdominal pain.
C) Ask the patient about nausea.
D) Check stools for occult blood.

Question 19

A patient is admitted to the emergency department (ED)for shock of unknown etiology.The first action by the nurse should be to

A) administer oxygen.
B) obtain a 12-lead electrocardiogram (ECG).
C) obtain the blood pressure.
D) check the level of consciousness.

Question 20

The emergency department (ED)nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute.In preparation for the patient's arrival,the nurse will obtain

A) hypothermia blanket.
B) lactated Ringer's solution.
C) two 14-gauge IV catheters.
D) dopamine (Intropin) infusion.

Question 21

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries.Which will the nurse complete first?

A) Start a normal saline infusion.
B) Give epinephrine (Adrenalin).
C) Start continuous ECG monitoring.
D) Give diphenhydramine (Benadryl).

Question 22

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis,which information is most important to report to the health care provider?

A) Temperature and IV site appearance
B) Oxygen saturation and breath sounds
C) Platelet count and presence of petechiae
D) Blood pressure, pulse rate, respiratory rate.

Question 23

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department.A cervical collar is in place.Which actions should the nurse take ?

A) Prepare to administer atropine IV.
B) Obtain baseline body temperature.
C) Infuse large volumes of lactated Ringer's solution.
D) Provide high-flow oxygen (100%) by non-rebreather mask.
E) Prepare for emergent intubation and mechanical ventilation.

Question 24

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/minute.The label on the infusion bag states: dobutamine 250 mg in 250 mL normal saline.When setting the infusion pump,the nurse will set the infusion rate at how many mL per hour?

Question 25

Which finding about a patient who is receiving vasopressin (Pitressin)to treat septic shock is most important for the nurse to communicate to the health care provider?

A) The patient's urine output is 18 mL/hr.
B) The patient's heart rate is 110 beats/minute.
C) The patient is complaining of chest pain.
D) The patient's peripheral pulses are weak.

Question 26

After change-of-shift report in the progressive care unit,who should the nurse care for first?

A) Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases
B) Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics
C) Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute
D) Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

Question 27

The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine)infusion through a right forearm IV.Which assessment finding obtained by the nurse indicates a need for immediate action?

A) The patient's heart rate is 58 beats/minute.
B) The patient's extremities are warm and dry.
C) The patient's IV infusion site is cool and pale.
D) The patient's urine output is 28 mL over the last hour.

Question 28

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90% on room air.In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A,B,C,D,E].)

A) Obtain blood and urine cultures.
B) Give vancomycin (Vancocin) 1 g IV.
C) Start norepinephrine (Levophed) 0.5 mcg/min.
D) Infuse normal saline 2000 mL over 30 minutes.
E) Titrate oxygen administration to keep O₂ saturation >95%.

Question 29

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS)in patients admitted to the hospital ?

A) Use aseptic technique when caring for invasive lines or devices.
B) Ambulate postoperative patients as soon as possible after surgery.
C) Remove indwelling urinary catheters as soon as possible after surgery.
D) Advocate for parenteral nutrition for patients who cannot take oral feedings.
E) Administer prescribed antibiotics within 1 hour for patients with possible sepsis.