Question 1

The nurse is caring for a young adult patient admitted with shock.The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.)

Accepted Answer

The level of consciousness assesses cerebral perfusion,urine output assesses renal perfusion,and blood pressure is a general indicator of systemic perfusion.Heart rate is not an indicator of perfusion.Pupillary response does not assess perfusion.Respirations do not assess perfusion.

Question 2

The nurse is caring for a patient admitted following a motor vehicle crash.Over the past 2 hours,the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion.To prevent complications,what is the priority nursing intervention?

Accepted Answer

Hypothermia is anticipated during the rapid infusion of fluids or blood products.Assessment of core body temperature is a priority.While administration of pain management,repositioning the patient every 2 hours,and application of heel protectors should be part of the patient care,given the rapid transfusion of blood products,these interventions are not the priority in this scenario.

Question 3

The nurse is caring for a patient in septic shock.The nurse assesses the patient to have a blood pressure of 105/60 mm Hg,heart rate 110 beats/min,respiratory rate 32 breaths/min,oxygen saturation (SpO₂)95% on 45% supplemental oxygen via Venturi mask,and a temperature of 102° F.The physician orders stat administration of an antibiotic.Which additional physician order should the nurse complete first?

Accepted Answer

Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock.A chest x-ray,Foley insertion,and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.

Question 4

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis.What findings assessed by the nurse indicate an appropriate response to therapy?

Accepted Answer

Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume.Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy.During fluid resuscitation in severe sepsis,intake and output will not be balanced as circulating fluid volume deficit is restored.

Question 5

After receiving a handoff report from the night shift,the nurse completes the morning assessment of a patient with severe sepsis.Vital sign assessment notes blood pressure 95/60 mm Hg,heart rate 110 beats/min,respirations 32 breaths/min,oxygen saturation ( SpO₂)96% on 45% oxygen via Venturi mask,temperature 101.5° F,central venous pressure ( CVP/RAP )2 mm Hg,and urine output of 10 mL for the past hour.The nurse initiates which active physician order first?

Accepted Answer

Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation.A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr.There is no evidence to support the need to increase supplemental oxygen.Administration of furosemide (Lasix)in the presence of a fluid volume deficit is contraindicated.

Question 6

The nurse is caring for a 70-kg patient in hypovolemic shock.Upon initial assessment,the nurse notes a blood pressure of 90/50 mm Hg,heart rate 125 beats/min,respirations 32 breaths/min,central venous pressure (CVP/RAP)of 3 mm Hg,and urine output of 5 mL during the past hour.Following physician rounds,the nurse reviews the orders and questions which order?

Accepted Answer

Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit.The nurse should question the use of the dopamine (Intropin)infusion.All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

Question 7

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours.Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%.What is the best interpretation of these findings by the nurse?

Accepted Answer

Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins.Hemoglobin and hematocrit results indicate hemodilution.Given the clinical scenario,there is no evidence to support the need for a blood transfusion and no evidence of fluid overload.Although administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third spacing of fluid,this fact does not support the hemoglobin and hematocrit results.

Question 8

The nurse is caring for a patient admitted with the early stages of septic shock.The nurse assesses the patient to be tachypneic,with a respiratory rate of 32 breaths/min.Arterial blood gas values assessed on admission are pH 7.50,CO₂ 28 mm Hg,HCO₃ 26.Which diagnostic study result reviewed by the nurse indicates progression of the shock state?

Accepted Answer

As shock progresses along the continuum,acidosis ensues,caused by metabolic acidosis,hypoxia,and anaerobic metabolism.A pH 7.30,CO₂ 45 mm Hg,HCO₃ 18 indicates metabolic acidosis and progression to a late stage of shock.All other listed arterial blood gas values are within normal limits.

Question 9

The nurse is administering intravenous norepinephrine ( Levophed )at 5 mcg/kg/min via a 20-gauge peripheral intravenous ( IV )catheter.What assessment finding requires immediate action by the nurse?

Accepted Answer

Swelling at the IV site is indicative of infiltration.Infusion of norepinephrine (Levophed)through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse.A blood pressure of 100/60 mm Hg,heart rate of 110 beats/min,and a CVP of 8 mm Hg are adequate and do not require immediate intervention.

Question 10

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis.As part of this patient's care plan,what intervention is most important for the nurse to discuss with the multidisciplinary care team?

Accepted Answer

Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa.Monitoring intake and output,frequent turning,and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission.

Question 11

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter ( CVC ).What action by the nurse best protects against the development of a central line-associated bloodstream infection ( CLABSI )?

Accepted Answer

Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines.Documentation of the line insertion date will assist in monitoring this measure.Elevation of the head of the bed,assessment for weaning readiness,and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia.

Question 12

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock,the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg,heart rate 135 beats/min,respirations 40 breaths/min,and a temperature of 102° F.The nurse notes the new onset of hematuria in the patient's Foley catheter.What are the priority nursing actions? (Select all that apply.)

Accepted Answer

In the event of a reaction,the transfusion is stopped,the patient is assessed,and both the physician and laboratory are notified.All transfusion equipment (bag,tubing,and remaining solutions)and any blood or urine specimens obtained are sent to the laboratory according to hospital policy.The events of the reaction,interventions used,and patient response to treatment are documented.Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction.The infusion must be stopped.Increasing the infusion further increases the likelihood of worsening the transfusion reaction.

Question 13

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex).The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m².The nurse measures a cardiac output,and the calculated cardiac index for the patient is 4.6 L/min/m².What is the best action by the nurse?

Accepted Answer

Dobutamine (Dobutrex)is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states improving overall cardiac performance.The patient's cardiac index is well above normal limits,so the rate of infusion of the medication should be reduced so as not to overstimulate the heart.There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram.Assessment of hourly urine output is important in the care of the patient in cardiogenic shock,but it is not a priority in this scenario.

Question 14

The nurse is caring for a patient in cardiogenic shock experiencing chest pain.Hemodynamic values assessed by the nurse include a cardiac index (CI)of 2.5 L/min/m²,heart rate of 70 beats/min,and a systemic vascular resistance (SVR)of 2200 dynes/sec/cm^-5.Upon review of physician orders,which order is most appropriate for the nurse to initiate?

Accepted Answer

The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR).To reduce afterload,ease the workload of the heart,and dilate the coronary arteries,improving oxygenation to the heart muscle,initiation of a nitroglycerin infusion is most appropriate.Assessment data do not support the initiation of other listed physician order options.

Quiz 11: Shock, sepsis, and Multiple Organ Dysfunction Syndrome

The nurse is caring for a young adult patient admitted with shock.The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.)

The nurse is caring for a patient admitted following a motor vehicle crash.Over the past 2 hours,the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion.To prevent complications,what is the priority nursing intervention?

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis.What findings assessed by the nurse indicate an appropriate response to therapy?

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours.Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%.What is the best interpretation of these findings by the nurse?

The nurse is administering intravenous norepinephrine ( Levophed ) at 5 mcg/kg/min via a 20-gauge peripheral intravenous ( IV ) catheter.What assessment finding requires immediate action by the nurse?

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis.As part of this patient's care plan,what intervention is most important for the nurse to discuss with the multidisciplinary care team?

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter ( CVC ) .What action by the nurse best protects against the development of a central line-associated bloodstream infection ( CLABSI ) ?