Chapter 67 Shock, SIRS, MODS

Question 1

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question?
Give PRN furosemide (Lasix) 40 mg IV.

Increase normal saline infusion to 250 mL/hr.

Administer hydrocortisone (Solu-Cortef) 100 mg IV.

Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

Answer 1

ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.

Question 2

A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question?
Infuse normal saline at 250 mL/hr.

Keep head of bed elevated to 30 degrees.

Hold nitroprusside (Nipride) if systolic BP <90 mm Hg.

Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

Answer 2

ANS: A
The patient’s elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the patient.

Question 3

A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
Inspiratory crackles.

Cool, clammy extremities.

Apical heart rate 45 beats/min.

Temperature 101.2° F (38.4° C).

Answer 3

ANS: C
Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Question 4

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next?
Increase the rate for the dopamine (Intropin) infusion.

Decrease the rate for the nitroglycerin (Tridil) infusion.

Increase the rate for the sodium nitroprusside (Nipride) infusion.

Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

Answer 4

ANS:C
Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

Question 5

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for:
nitroglycerine (Tridil).

norepinephrine (Levophed).

sodium nitroprusside (Nipride).

methylprednisolone (Solu-Medrol).

Answer 5

ANS: B
When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside is an arterial vasodilator and would further decrease SVR.

Question 6

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?
Auscultate bowel sounds.

Palpate for abdominal pain.

Ask the patient about nausea.

Check stools for occult blood.

Answer 6

ANS: A
Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration.

Question 7

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication?
5% human albumin

Furosemide (Lasix) IV

Epinephrine (Adrenalin) drip

Hydrocortisone (Solu-Cortef)

Answer 7

ANS: B
The PAWP indicates that the patient’s preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

Question 8

The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patient’s arrival, the nurse will obtain:
hypothermia blanket.

lactated Ringer’s solution.

two 14-gauge IV catheters.

dopamine (Intropin) infusion.

Answer 8

ANS: C
A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer’s solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

Question 9

Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective?
Hemoglobin is within normal limits.

Urine output is 60 mL over the last hour.

Central venous pressure (CVP) is normal.

Mean arterial pressure (MAP) is 72 mm Hg.

Answer 9

ANS: B
Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

Question 10

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
Check temperature every 2 hours.

Monitor breath sounds frequently.

Maintain patient in supine position.

Assess skin for flushing and itching.

Answer 10

ANS: B
Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Question 11

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?
The patient’s central venous pressure is 3 mm Hg.

The patient is in sinus tachycardia at 120 beats/min.

The patient is receiving low dose dopamine (Intropin).

The patient has had no urine output since being admitted.

Answer 11

ANS: A
Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient’s low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

Question 12

A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective?
No new heart murmurs

Decreased troponin level

Warm, pink, and dry skin

Blood pressure 92/40 mm Hg

Answer 12

ANS: C
Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

Question 13

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?
Heart rate

Orientation

Blood pressure

Oxygen saturation

Answer 13

ANS: D
Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock

Question 14

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?
The patient’s serum creatinine level is elevated.

The patient complains of intermittent chest pressure.

The patient’s extremities are cool and pulses are weak.

The patient has bilateral crackles throughout lung fields.

Answer 14

ANS: A
The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patient’s diagnosis of cardiogenic shock.

Question 15

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?
Give normal saline IV at 500 mL/hr.

Give acetaminophen (Tylenol) 650 mg rectally.

Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.

Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

Answer 15

ANS: A
Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

Question 16

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?
Placing the pulse oximeter on the ear for a patient with septic shock

Keeping the head of the bed flat for a patient with hypovolemic shock

Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR

Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock

Answer 16

ANS: D
Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

Question 17

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
Blood pressure (BP) 92/56 mm Hg 

Skin cool and clammy

Oxygen saturation 92%

Heart rate 118 beats/minute

Answer 17

ANS: B
Because patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient’s status.

Question 18

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to:
administer oxygen.

obtain a 12-lead electrocardiogram (ECG).

obtain the blood pressure.

check the level of consciousness.

Answer 18

ANS: A
The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.

Question 19

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?
New onset of confusion

Heart rate 112 beats/minute

Decreased bowel sounds

Pale, cool, and dry extremities

Answer 19

ANS: A
The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

Question 20

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first?
Insert two large-bore IV catheters.

Initiate continuous electrocardiogram (ECG) monitoring.

Provide oxygen at 100% per non-rebreather mask.

Draw blood to type and crossmatch for transfusions.

Answer 20

ANS: C
The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize oxygen delivery have been implemented.

Question 21

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?
The patient’s heart rate is 58 beats/minute.

The patient’s extremities are warm and dry.

The patient’s IV infusion site is cool and pale.

The patient’s urine output is 28 mL over the last hour.

Answer 21

ANS: C
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.

Question 22

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?
Start a normal saline infusion.

Give epinephrine (Adrenalin).

Start continuous ECG monitoring.
 Give diphenhydramine (Benadryl).

Answer 22

ANS: B
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 23

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?
The patient’s urine output is 18 mL/hr.

The patient’s heart rate is 110 beats/minute.

The patient is complaining of chest pain.

The patient’s peripheral pulses are weak.

Answer 23

ANS: C
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 24

After change-of-shift report in the progressive care unit, who should the nurse care for first?
Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases

Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics

Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54
beats/minute

Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of
108/58 mm Hg

Answer 24

ANS: B
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 25

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?
Temperature and IV site appearance

Oxygen saturation and breath sounds

Platelet count and presence of petechiae

Blood pressure, pulse rate, respiratory rate.

Answer 25

ANS: C
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 26

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)?
Prepare to administer atropine IV.

Obtain baseline body temperature.

Infuse large volumes of lactated Ringer’s solution.

Provide high-flow oxygen (100%) by non-rebreather mask.

Prepare for emergent intubation and mechanical ventilation.

Answer 26

ANS: A, B, D, E
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 27

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)?
Use aseptic technique when caring for invasive lines or devices.

Ambulate postoperative patients as soon as possible after surgery.

Remove indwelling urinary catheters as soon as possible after surgery.

Advocate for parenteral nutrition for patients who cannot take oral feedings.

Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

Answer 27

ANS: A, B, C, E
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 28

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?

Answer 28

ANS: 27
In order to administer the dobutamine at the prescribed rate of 5 mcg/kg/minute from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hour.

Question 29

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].)
Obtain blood and urine cultures.

Give vancomycin (Vancocin) 1 g IV.

Start norepinephrine (Levophed) 0.5 mcg/min.

Infuse normal saline 2000 mL over 30 minutes.

Titrate oxygen administration to keep O2 saturation >95%.

Answer 29

ANS: E, D, C, A, BThe 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.