Shock NCLEX Questions, Nclex Questions for Shock - Critical Care, Sepsis

Shock NCLEX Questions, Nclex Questions for Shock - Critical Care, Sepsis

NCLEX, Ch 67: shock, SIRS, MODS

ScienceMedicineEmergency Medicine felicia_ramnandan Save Nclex Questions for Shock - Critical ...32 terms karmageniePreview Shock and Sepsis NCLEX questions 28 terms T_Adams7Preview

Nursing Management: Shock & MO...

27 terms HelpfulNurseEdu Preview Shock, 19 terms kae A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock?a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Distributive a.) Hypovolemic

• 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?

• Give furosemide (Lasix) 40 mg IV.
• Increase normal saline infusion to 150 mL/hr.
• Administer hydrocortisone (SoluCortef) 100 mg IV.
• Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.

ANS: A

Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.DIF: Cognitive Level: Application REF: 1724-1726 | 1731 | 1733 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

What will the nurse identify as symptoms of hypovolemic shock in a patient?Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

• Temperature of 97.6°F (36.4°C)
• Restlessness
• Decrease in blood pressure of 20 mm Hg when the patient sits up
• Capillary refill time greater than 3 seconds
• Sinus bradycardia of 55 beats per minute

Correct Answer: 2,3,4

Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate.Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status.

Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock.

Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced.Rationale 5: Bradycardia is not present. The compensatory response is to increase the heart rate to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.Why are the manifestations of most types of shock the same regardless of what specific events or condition caused the shock to occur?

• The blood, blood vessels, and heart are directly connected to each other so that when one is affected, all three are affected.
• Because blood loss occurs with all types of shock, the most common first manifestation is hypotension.
• Every type of shock interferes with oxygenation and metabolism of all cells in the same sequence.
• The sympathetic nervous system is triggered by any type of shock and initiates the stress response.

ANS: D

Rationale: Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs.These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems.

• 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?

• Infuse normal saline at 250 mL/hr.
• Keep head of bed elevated to 30 degrees.
• Give nitroprusside (Nipride) unless systolic BP <90 mm Hg.
• Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

ANS: A

The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.DIF: Cognitive Level: Application REF: 1719 | 1721-1722 | 1735 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take?a.) Slow the IV infusion rate b.) Administer dopamine c.) No interventions are needed at this time d.) Increase the IV infusion rate d.) Increase the IV infusion rate Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective?

• Urine output increase from 5 mL/hr to 25 mL/hr
• Pulse pressure decrease from 35 mm Hg to 28 mm Hg
• Respiratory rate increase from 22 breaths/min to 26 breaths/min
• Core body temperature increase from 98.2 F (36.8 C) to 98.8 F (37.1 C)

ANS: A

Rationale: During shock, the kidneys and baroreceptors sense an ongoing decrease in MAP and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume.Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output.These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase.Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock?

• Serum sodium of 130 mEq/L (130 mmol/L)
• Metabolic acidosis validated by arterial blood gases
• Serum lactate of 3 mmol/L
• SvO2 greater than 80%

Correct Answer: 2

Rationale 1: The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not reduced.Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion.Rationale 3: Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock.Rationale 4: SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased.A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock?a.) Distributive b.) Neurogenic c.) Obstructive d.) Cardiogenic c.) Obstructive

Rationale:

Obstructive shock can be caused by anything that impedes the heart's ability to contract and pump blood around the body, as with cardiac tamponade.

The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with:

• Decreased cardiac output
• Severe constipation, causing watery diarrhea
• Ascites
• Syndrome of inappropriate ADH (SIADH)

Correct Answer: 3

Rationale 1: Although ECG changes reflect the effectiveness of the heart's pumping when circulating the blood, it is not a risk factor for hypovolemic shock, which reflects a decreased circulating volume from either blood or fluid losses within the intravascular system.

Rationale 2: Severe constipation does not affect the circulating blood volume.

Rationale 3: Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock.Rationale 4: Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema.Which newly admitted client does the nurse consider to be at highest risk for development of sepsis?

• 75-year-old man with hypertension and early Alzheimer's disease
• 68-year-old woman 2 days postoperative from bowel surgery
• 80-year-old community-dwelling man with no other health problems undergoing cataract surgery
• 54-year-old woman with moderate asthma and severe degenerative joint disease of the right knee

ANS: B

Rationale: The 68-year-old woman has several risk factors. First she is an older adult, and immune function decreases with age. The greatest risk factor is that she has just had bowel surgery. Not only does major surgery further reduce the immune response, the bowel cannot be "sterilized" for surgery. Therefore the usual bacteria of the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted.

• 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?

• Cool, clammy skin
• Inspiratory crackles
• Apical heart rate 48 beats/min
• Temperature 101.2° F (38.4° C)

ANS: C

Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.DIF: Cognitive Level: Comprehension REF: 1721-1722 | 1723 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity