Question 1

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

D

Question 2

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 88/48. Which order is the current priority?

Accepted Answer

The patient's low urine output is indicative of hypovolemia and requires immediate intervention with isotonic fluids to improve fluid status and perfusion to vital organs. Placing the patient on a warming blanket and drawing blood for BUN and creatinine can be important interventions, but they are not as urgent as addressing the hypovolemia. The use of a kinetic bed may be helpful, but it is not the current priority.

Question 3

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

The patient's increasing lethargy and periods of apnea suggest that their level of consciousness is decreasing and they are at risk for further airway compromise. Endotracheal intubation is the most effective way to protect the airway in this situation. Monitoring oxygen saturation is important, but it does not address the need to secure the airway. Assessment of breath sounds and asking the patient if it is becoming difficult to breathe are also important, but they do not provide a solution to the decreasing level of consciousness and risk for airway obstruction.

Question 4

The nurse is reviewing the diagnostic tests for a patient with an infection. Which test result would the nurse attribute to this diagnosis?

Accepted Answer

The answer of The nurse is reviewing the diagnostic tests...

Question 5

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

Accepted Answer

Septic shock is defined as sepsis with persisting hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status. Option A describes respiratory failure, but not necessarily shock; Option B describes a patient who is febrile but doesn't mention low blood pressure or perfusion abnormalities; Option D describes leukocytosis and fever, but not necessarily shock. Option C describes a patient with an infection who has persisting hypotension despite receiving IV fluids, which is a defining characteristic of septic shock.

Question 6

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 medication used to increase blood pressure in patients with shock. Therefore, monitoring the patient's blood pressure would be the best way to evaluate the effectiveness of this medication.

Question 7

The critical care nurse is delivering a peer lecture on guidelines for the management of SIRS and severe sepsis. Which intervention would the nurse describe as improving outcomes in septic shock?

Accepted Answer

Maintaining blood glucose lower than 150 mg/dL is associated with improved outcomes in septic shock by reducing complications related to hyperglycemia.

Question 8

The nurse plans to administer normal saline to a patient with systemic inflammatory response syndrome SIRS) and hypotension. At which rate would the nurse anticipate administering this fluid?

Accepted Answer

In SIRS and hypotension, the patient requires rapid fluid resuscitation. The initial fluid therapy is typically administered at a rate of 500mL/hr until an appropriate response is achieved. The other options mentioned are not appropriate for this situation.

Question 9

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 happens in an attempt to maintain blood flow to vital organs such as the heart and brain. As a result, the patient's hands may feel cold to the touch.

Question 10

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

Accepted Answer

The answer of The nurse will plan which interventions to...

Question 11

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

Accepted Answer

Patients who have undergone a mastectomy have a higher risk for hypovolemic shock due to blood loss during the procedure. The other patients may have different potential complications related to their medical history but not specifically related to hypovolemic shock.

Question 12

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

Deprivation of oxygen during shock can cause organs to fail to function properly, leading to MODS. As the body tries to compensate for the sepsis, it can lead to decreased blood flow to vital organs, causing hypoxia and subsequent organ dysfunction.

Question 13

Which patients would the nurse identify as being at increased risk for the development of hypovolemic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of Which patients would the nurse identify as...

Question 14

The nurse would identify which patients as being at increased risk for development of sepsis and septic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of The nurse would identify which patients as...

Question 15

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 can decrease heart rate and limit the body's ability to compensate for shock by increasing cardiac output. Therefore, the patient may not exhibit tachycardia as an early sign of shock.

Question 16

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 17

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

An indwelling urinary catheter inserted 3 days ago by nursing home personnel can be a likely source of sepsis in an 80-year-old patient. The catheter can cause a urinary tract infection, which can lead to sepsis. The other options, such as a rash or exposure to chemotherapy, may not be as likely to cause sepsis in this patient population.

Question 18

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 complication of a myocardial infarction and can lead to cardiogenic shock, which occurs when the heart cannot effectively pump enough blood to meet the body's demands. Septic shock occurs from overwhelming bacterial infection, anaphylactic shock from an allergic reaction, and neurogenic shock from a spinal cord injury or damage.

Question 19

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 lead to decreased tissue perfusion and therefore decreased tissue oxygenation. This can result in changes in mental status, making it the primary concern for the nurse to assess and address. While anxiety and fear of death can contribute to changes in mental status, it is not the primary concern in this situation. Metastasis of underlying cancer is a potential concern in a patient undergoing chemotherapy, but it is not directly related to the change in mental status observed by the nurse. Similarly, while chemotherapy can have side effects, it is unlikely to be the sole cause of a sudden change in mental status in a patient with septic shock.

Question 20

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

Accepted Answer

The answer of The nurse anticipates assisting with which therapy...

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