Question 1

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?

Accepted Answer

Warm,pink,and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator,the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

Question 2

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?

Accepted Answer

Because patients in the early stage of septic shock have warm and dry skin,the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported,but does not indicate deterioration of the patient's status.

Question 3

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg,a pulse of 64 beats/min,and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question?

Accepted Answer

The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability,consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions will help to improve cardiac output,which should lower the PAWP and may raise the BP.

Question 4

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question?

Accepted Answer

Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock require large amounts of fluid replacement. If the patient remains hypotensive after initial volume resuscitation with minimally 30 mL/kg,vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.

Question 5

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?

Accepted Answer

The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

Question 6

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

Accepted Answer

Because the airway edema that is associated with anaphylaxis can affect airway and breathing,the O? saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

Question 7

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

Accepted Answer

Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock,the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Question 8

Norepinephrine 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?

Accepted Answer

Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

Question 9

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

Accepted Answer

Because of the decreased preload associated with septic shock,fluid resuscitation is the initial therapy. The other actions also are appropriate,and should be initiated quickly as well.

Question 10

The emergency department (ED)nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival,the nurse will obtain

Accepted Answer

A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock,so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

Question 11

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

Accepted Answer

Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done,but these will not help in determining the effectiveness of the pantoprazole administration.

Question 12

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?

Accepted Answer

The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring,insertion of IV catheters,and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O? delivery have been implemented.

Question 13

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?

Accepted Answer

The PAWP indicates that the patient's preload is elevated,and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

Question 14

A 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?

Accepted Answer

Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Question 15

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?

Accepted Answer

Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

Question 16

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

Accepted Answer

Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload,which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

Question 17

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)?

Accepted Answer

The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles,chest pressure,and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock.

Question 18

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

Accepted Answer

The initial actions of the nurse are focused on the ABCs-airway,breathing,and circulation-and administration of O₂ should be done first. The other actions should be accomplished as rapidly as possible after providing O₂.

Question 19

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

Accepted Answer

When fluid resuscitation is unsuccessful,vasopressor drugs are given to increase the systemic vascular resistance (SVR)and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

Question 20

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?

Accepted Answer

Assessment of end organ perfusion,such as an adequate urine output,is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level,CVP,and MAP are useful in determining the effects of fluid administration,but they are not as useful as data indicating good organ perfusion.

Quiz 66: Shock, sepsis, and Multiple Organ Dysfunction Syndrome

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?

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 nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg,a pulse of 64 beats/min,and an elevated pulmonary artery wedge pressure (PAWP) . Which intervention ordered by the health care provider should the nurse question?

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question?

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?

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

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

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

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival,the nurse will obtain

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 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 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 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?

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?

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

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

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

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?