Question 1

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 (select all that apply)?

Accepted Answer

All of the actions are appropriate except to give large volumes of lactated Ringer's solution.The patient with neurogenic shock usually has a normal blood volume,and it is important not to volume overload the patient.In addition,lactated Ringer's solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.

Question 2

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

Accepted Answer

Because sepsis is the most frequent etiology for SIRS,measures to avoid infection such as removing indwelling urinary catheters as soon as possible,use of aseptic technique,and early ambulation should be included in the plan of care.Adequate nutrition is important in preventing SIRS.Enteral,rather than parenteral,nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine,thus decreasing infection risk.Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

Question 3

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?

Accepted Answer

Epinephrine rapidly causes peripheral vasoconstriction,dilates the bronchi,and blocks the effects of histamine and reverses the vasodilation,bronchoconstriction,and histamine release that cause the symptoms of anaphylaxis.The other interventions are also appropriate but would not be the first ones completed.

Question 4

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?

Accepted Answer

The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome (MODS)is developing.The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.

Question 5

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?

Accepted Answer

Because vasopressin is a potent vasoconstrictor,it may decrease coronary artery perfusion.The other information is consistent with the patient's diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy.

Question 6

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?

Accepted Answer

The answer of A 198-lb patient is to receive a...

Question 7

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].)

Accepted Answer

The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation,followed by infusion of IV fluids and vasopressors to improve perfusion.Cultures should be obtained before administration of antibiotics.

Question 8

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

Accepted Answer

Antibiotics should be administered within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS)and septic shock.The data on the other patients indicate that they are more stable.Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction.Mild bradycardia does not usually require atropine in patients who have a spinal cord injury.The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.

Question 9

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?

Accepted Answer

The coldness and pallor at the infusion site suggest extravasation of the phenylephrine.The nurse should discontinue the IV and,if possible,infuse the medication into a central line.An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention.A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour,but an immediate change in therapy is not indicated.Warm,dry skin is consistent with early neurogenic shock,but it does not indicate a need for a change in therapy or immediate action.

Quiz 63: Nursing Management: Shock,systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome

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 (select all that apply) ?

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

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?

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?

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 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?

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].)

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

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?