Shock, Sepsis Multiple Organ Dysfunction NCLEX, Exam 4: Shock NCLEX

Shock, Sepsis & Multiple Organ Dysfunction NCLEX, Exam 4: Shock NCLEX

Questions, Nclex Questions for Shock - Critical Care, NCLEX Cardiac Critical Care, Critical Care nclex, Nclex Questions for Shock - Critical Care, Shock NCLEX Questions, Chapter 37...ScienceMedicineNursing anniedang_9Top creator on Quizlet Save Shock and Sepsis NCLEX questions 28 terms T_Adams7Preview Shock NCLEX Questions, Nclex Que...201 terms felicia_ramnandan P Preview Nclex Questions for Shock - Critical ...32 terms karmageniePreview Shock 37 terms ann The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action?

• Assess the blood pressure by Doppler.
• Estimate the systolic pressure as 60 mm Hg.
• Obtain an electronic blood pressure monitor.
• Record the blood pressure as not assessable.

A ~ Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is not appropriate without further attempts using different modalities.The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess?

• Breath sounds and capillary refill
• Blood pressure and oral temperature
• Oral temperature and capillary refill
• Right atrial pressure and urine output

D ~ Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems.

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is

• L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse?
• The assessed values are within normal limits.
• The patient is at risk for developing cardiogenic shock.
• The patient is at risk for developing fluid volume overload.
• The patient is at risk for developing hypovolemic shock.

D ~ Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention?

• Human albumin infusion
• Hypotonic saline solution
• Lactated Ringer's bolus
• Packed red blood cells

C ~ The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses.Which hemodynamic values is the nurse most likely to assess?

• High pulmonary artery occlusive pressure and high cardiac output
• High systemic vascular resistance and low cardiac output
• Low pulmonary artery occlusive pressure and low cardiac output
• Low systemic vascular resistance and high cardiac output

D ~ As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In the early stages of septic shock, cardiac output is high.The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102 F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first?

• Acetaminophen suppository
• Blood cultures from two sites
• IV antibiotic administration
• Isotonic fluid challenge

D ~ Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario.

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?

• A patient admitted with abdominal pain and an elevated white blood cell count
• A patient with a temperature of 102 F and a general dermal rash
• A patient with a 2-day history of nausea, vomiting, and diarrhea
• A patient with slight rectal bleeding from inflamed hemorrhoids

C ~ Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention?

• Dobutamine (Dobutrex)
• Furosemide (Lasix)
• Phenylephrine (Neo-Synephrine)
• Sodium nitroprusside (Nipride)

A ~ Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor.Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention?

• Diphenhydramine (Benadryl) 50 mg intravenously

b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously

• Methylprednisolone (Solu-Medrol) 125 mg intravenously
• Ranitidine (Zantac) 50 mg intravenously

B ~ The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine (Benadryl) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone (Solu-Medrol), are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine (Zantac) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess?

• High pulmonary artery diastolic pressure and low cardiac output
• Low pulmonary artery occlusive pressure and low cardiac output
• Low systemic vascular resistance and high cardiac output
• Normal cardiac output and low systemic vascular resistance

A ~ In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.

During the initial stages of shock, what are the physiological effects of decreased cardiac output?

• Arterial vasodilation
• High urine output
• Increased parasympathetic stimulation
• Increased sympathetic stimulation

D ~ A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority?

• Central nervous system
• Gastrointestinal system
• Renal system
• Respiratory system

A ~ The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP?

• The action of the machine will improve blood supply to the damaged heart.
• The machine will beat for the damaged heart with every beat until it heals.
• The machine will help cleanse the blood of impurities that might damage the heart.
• The machine will remain in place until the patient is ready for a heart transplant.

A ~ The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not beat for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy?

• Cardiac index (CI) of 2.5 L/min/m2
• Pulmonary artery diastolic pressure of 26 mm Hg
• Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg
• Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5

A ~ Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are high and would not indicate an appropriate response to therapy.