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

Question 1

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

Answer 1

New onset of confusion and agitation

Question 2

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.

Answer 2

administer oxygen.

Question 3

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 ).

Answer 3

norepinephrine ( Levophed ).

Question 4

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.

Question 5

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.

Question 6

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.
D) Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

Question 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).

Question 8

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.

Question 9

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%

Question 10

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.

Question 11

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.

Question 12

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

Question 13

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.

Question 14

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 of these prescribed interventions will the nurse implement first?

A) Give normal saline IV at 500 mL/hr.
B) Infuse drotrecogin-a ( 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.

Question 15

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 101.2° F ( 38.4° C )

Question 16

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.

Question 17

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.

Question 18

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

Question 19

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.

Question 20

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.

Question 21

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.

Question 22

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.

Question 23

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 solve 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%.

Question 24

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.

Question 25

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)