Deck 67: Nursing Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome

Question 1

While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding

A) cold, mottled extremities.
B) restlessness and apprehension.
C) a heart rate of 120 and cool, clammy skin.
D) systolic BP less than 90 mm Hg.

Answer 1

restlessness and apprehension.

Question 2

The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include

A) pH 7.48, PaCO₂ 33 mm Hg.
B) pH 7.33, PaCO₂ 30 mm Hg.
C) pH 7.41, PaCO₂ 50 mm Hg.
D) pH 7.38, PaCO₂ 45 mm Hg.

Answer 2

pH 7.33, PaCO₂ 30 mm Hg.

Question 3

A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate

A) administration of furosemide (Lasix) IV.
B) titration of an epinephrine (Adrenalin) drip.
C) administration of a normal saline bolus.
D) assisting with endotracheal intubation.

Answer 3

administration of furosemide (Lasix) IV.

Question 4

The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's

A) urine output is 40 ml over the last hour.
B) hemoglobin is within normal limits.
C) CVP has decreased.
D) mean arterial pressure (MAP) is 65 mm Hg.

Question 5

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

A) check the blood pressure.
B) obtain an oxygen saturation.
C) attach a cardiac monitor.
D) check level of consciousness.

Question 6

When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and nitroglycerin (Tridil) infusions, the best evidence that the medications are effective is that the

A) systolic BP increases to greater than 100 mm Hg.
B) cardiac monitor shows sinus rhythm at 96 beats/min.
C) PAWP drops to normal range.
D) troponin and creatine kinase levels decrease.

Question 7

While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient's bed is elevated to 75 degrees. This finding indicates a need for

A) additional fluid replacement.
B) antibiotic administration.
C) infusion of a sympathomimetic drug.
D) administration of increased oxygen.

Question 8

All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who develops severe respiratory distress and faintness. Which one will the nurse administer first?

A) Epinephrine (Adrenalin)
B) Normal saline infusion
C) Dexamethasone (Decadron)
D) Diphenhydramine (Benadryl)

Question 9

The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to

A) arrange for the hospital pastoral care staff to visit the patient.
B) ask the health care provider to prescribe a sedative drug for the patient.
C) leave the patient alone with family members whenever possible.
D) place the patient's call bell where it can be easily reached.

Question 10

Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the drug, the nurse ensures that the

A) patient's heart rate is less than 100.
B) patient has received adequate fluid replacement.
C) patient's urine output is within normal range.
D) patient is not receiving other sympathomimetic drugs.

Question 11

A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

A) Insert two 14-gauge IV catheters.
B) Administer oxygen at 100% per non-rebreather mask.
C) Place the patient on continuous cardiac monitor.
D) Draw blood to type and crossmatch for transfusions.

Question 12

A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)?

A) Administer all medications through the patient's indwelling central line.
B) Place the patient in a private room.
C) Restrict the patient to foods that have been well-cooked or processed.
D) Insert a nasogastric (NG) tube for enteral feeding.

Question 13

The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left-forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action?

A) The patient has an apical pulse rate of 58 beats/min.
B) The patient's urine output has been 28 ml over the last hour.
C) The patient's IV infusion site is cool and pale.
D) The patient has warm, dry skin on the extremities.

Question 14

A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the

A) progressive stage of septic shock.
B) compensatory stage of diabetic shock.
C) refractory stage of cardiogenic shock.
D) progressive stage of hypovolemic shock.

Question 15

The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain

A) a liter of lactated Ringer's solution.
B) 500 ml of 5% albumin.
C) two 14-gauge IV catheters.
D) a retention catheter.

Question 16

A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is

A) activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries.
B) stimulation of cardiac b-adrenergic receptors, leading to increased cardiac output.
C) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.
D) movement of interstitial fluid to the intravascular space, increasing renal blood flow.

Question 17

When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the

A) cardiac output is increased and the central venous pressure (CVP) is low.
B) pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low.
C) heart rate is decreased, and the systemic vascular resistance is low.
D) cardiac output is decreased and the PAWP is high.

Question 18

The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy?

A) The patient is restless and anxious.
B) The patient has a heart rate of 134.
C) The patient has hypotonic bowel sounds.
D) The patient has a temperature of 94.1° F.

Question 19

A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of

A) cool, clammy skin.
B) shortness of breath.
C) heart rate of 48 beats/min
D) BP of 82/40 mm Hg.

Question 20

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of

A) nitroglycerine (Tridil).
B) dobutamine (Dobutrex).
C) norepinephrine (Levophed).
D) sodium nitroprusside (Nipride).

Question 21

An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes

A) respiratory rate of 10 breaths/min.
B) fixed urine specific gravity at 1.010.
C) MAP of 55 mm Hg.
D) 360-ml urine output in 8 hours.

Question 22

When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse?

A) BP 88/56 mm Hg
B) Apical pulse 110 beats/min
C) Urine output 15 ml for 2 hours
D) Arterial oxygen saturation 90%

Question 23

A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock?

A) The cardiac output is elevated.
B) The central venous pressure (CVP) is increased.
C) The systemic vascular resistance (SVR) is high.
D) The PAWP is high.

Question 24

To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are

A) stool guaiac and bowel sounds.
B) lung sounds and oxygenation status.
C) serum creatinine and urinary output.
D) serum bilirubin levels and skin color.

Question 25

A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is

A) urine output of 0.5 ml/kg/hr.
B) decreased peripheral edema.
C) decreased CVP.
D) oxygen saturation 90% or more.

Question 26

When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS?

A) The patient has crackles throughout both lung fields.
B) The patient complains of 8/10 crushing chest pain.
C) The patient has an elevated ammonia level and confusion.
D) The patient has cool extremities and weak pedal pulses.

Question 27

A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first?

A) Start insulin drip to maintain blood glucose at 110 to 150 mg/dl.
B) Give normal saline IV at 500 ml/hr.
C) Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg.
D) Infuse drotrecogin-a (Xigris) 24 mcg/kg.