E2/11 Flashcards
- A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client’s health problem?
A. Blood is shunted from vital organs to peripheral areas of the body.
B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
C. Circulating blood volume is decreased with a resulting change in the osmoticpressure gradient.
D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequateperfusion.
B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
In cases of shock, blood is shunted from peripheral areas of the
body to the vital organs. Hemorrhage and decreased blood volume are associated with
some, but not all, types of shock.
In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client’s care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client’s care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances?
A. Fluid volume circulating in the blood vessels decreases.
B. There is an uncontrolled increase in cardiac output.
C. Blood pressure regulation becomes irregular.
D. The client experiences tachycardia and a bounding pulse.
B. There is an uncontrolled increase in cardiac output.
C. Blood pressure regulation becomes irregular.
D. The client experiences tachycardia and a bounding pulse.
A. Fluid volume circulating in the blood vessels decreases.
Hypovolemic shock is characterized by a decrease in intravascular volume.
Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.
The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
A. Increased urine output
B. Decreased heart rate
C. Hyperactive bowel sounds
D. Cool, clammy skin
D. Cool, clammy skin
Compensatory stage of shock, the body shunts blood from the organs, such asthe skin and kidneys, to the brain and heart to ensure adequate blood supply. As aresult, the patients skin is cool and clammy. Also in this compensatory stage, bloodvessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and theurine output decreases
The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer?
A. Lactated Ringer
B. Albumin
C. Dextran
D. 3% NaCl
A. Lactated Ringer
Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock.
A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse’s care planning during the administration of a vasoactive drug?
A. The drug should be discontinued immediately after blood pressure increases.
B. The drug dose should be tapered down once vital signs improve.
C. The client should have arterial blood gases drawn every 10 minutes during treatment.
D. The infusion rate should be titrated according the client’s subjective sensation of
adequate perfusion.
B. The drug dose should be tapered down once vital signs improve.
When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state.
A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client’s blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU
nurse recognize that the client is probably experiencing?
A. Anaphylactic shock
B. Neurogenic shock
C. Septic shock
D. Hypovolemic shock
B. Neurogenic shock
Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation
The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client’s nutritional needs. Which physiologic process contributes to these increased nutritional needs?
A. The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate
B. The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity
C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements
D. The increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea
C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements
Nutritional support is an important aspect of care for clients in shock. Clients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements.
The special nutritional needs of shock are related to increased sympathetic activity
The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention?
A. Reviewing the cause of shock and prioritizing the client’s psychosocial needs
B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
C. Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive
D. Promoting the client’s coping skills in an effort to better deal with the physiologic changes accompanying shock
B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
Nursing care of clients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of clients in shock; thus, suspecting that a client may be in shock and reporting subtle changes in assessment are imperative.
When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal?
A. Provide a detailed diagnosis and plan of care in order to promote the client’s and family’s coping.
B. Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions.
C. Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature.
D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the client with the best chance for recovery.
The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse’s plan of care should include what intervention?
A. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good
B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months
C. Promoting communication with the client and family along with addressing end-of-life issues
D. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
C. Promoting communication with the client and family along with addressing end-of-life issues
Many cases of MODS result in death, and the life expectancy of clients with MODS is usually measured in hours and possibly days, but not in months.
The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role
of antidiuretic hormone during hypovolemic shock?
A. Increased hunger
B. Decreased thirst
C. Decreased urinary output
D. Increased capillary perfusion
C. Decreased urinary output
During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further retain water in an effort to raise blood volume and blood pressure. In a hypovolemic state
the body shifts blood away from anything that is not a vital organ
The nurse is caring for a client whose worsening/progressing infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock?
A. Elevated systolic blood pressure
B. Elevated mean arterial pressure (MAP)
C. Shallow, rapid respirations
D. Bradycardia
C. Shallow, rapid respirations
A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg.
The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor?
A. Hypothermia
B. Bradycardia
C. Coffee ground emesis
D. Pain
A. Hypothermia
Temperature should be monitored closely to ensure that rapid fluid
resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the client for cardiovascular overload and pulmonary edema when large volumes of IV solution are given.
The nurse is caring for a client in intensive care unit whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. Which assessments and interventions should the nurse prioritize?
A. Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration
B. Reviewing medications, performing a focused cardiovascular assessment, and providing client education
C. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema
D. Routine monitoring of vital signs, monitoring the peripheral intravenous site, and providing early discharge instructions
A. Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration
Dopamine is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. When vasoactive medications are given, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be given through a central because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. High doses can cause vasoconstriction, which increases afterload and thus increases cardiac workload. Because this effect is undesirable in clients with cardiogenic shock, dopamine doses must be carefully titrated.
A nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse’s assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse’s analysis of these data should lead to which preliminary conclusion?
A. The client is in the compensatory stage of shock.
B. The client is in the progressive stage of shock.
C. The client will stabilize and be released by tomorrow.
D. The client is in the irreversible stage of shock.
A. The client is in the compensatory stage of shock.
In the compensatory stage of shock, the blood pressure remains within normal limits. Clients display the often-described
“fight or flight” response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive.
The nurse in a rural nursing facility will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after giving birth at home. Which principle should guide the nurse’s administration of intravenous fluid?
A. 5% albumin is preferred because it is inexpensive and is always readily available.
B. Dextran should be given because it increases intravascular volume and counteracts coagulopathy.
C. Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency.
D. Lactated Ringer solution is ideal because it increases volume, buffers acidosis, and is the best choice for clients with liver failure.
C. Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency.
In emergencies, the “best” fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids can be administered to restore intravascular volume.
The nurse in the intensive care unit is caring for a 47-year-old, obese client who is in shock following a motor vehicle accident. What would be the main challenge in meeting this client’s elevated energy requirements during prolonged rehabilitation?
A. Loss of adipose tissue
B. Loss of skeletal muscle
C. Inability to convert adipose tissue to energy
D. Inability to maintain normal body mass
B. Loss of skeletal muscle
Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the client has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the client’s recovery time.
The nurse in the emergency department is caring for a client recently admitted with a likely myocardial infarction (MI). The nurse understands that the client’s heart is pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at
an increased risk for MI due to which factor?
A. Arrhythmias
B. Elevated B-natriuretic peptide (BNP)
C. Use of thrombolytics
D. Dehydration
A. Arrhythmias
Cardiogenic shock occurs when the heart’s ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. An elevated BNP is noted after an MI has occurred and does not increase risk. Use of thrombolytics decreases risk of developing blood clots. Dehydration does not lead to MI.
CAN ALSO BE DYSRHYTHMIAS
The nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client?
A. It promotes coping and slows catecholamine release.
B. It stimulates the client so he or she is more alert.
C. It decreases gastric secretions.
D. It dilates the blood vessels.
D. It dilates the blood vessels.
For clients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the client’s anxiety.
The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will
increase the client’s cardiac output during the hypovolemic state?
A. Third spacing of fluid
B. Dysrhythmias
C. Tachycardia
D. Gastric hypermotility
C. Tachycardia
Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states.
The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply.
A. Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines
B. Hypotension that responds to bolus fluid resuscitation
C. Exaggerated response to vasoactive medications
D. Serum lactate greater than 4 mmol/L
E. Mean arterial pressure (MAP) of less than 65 mmHg
A. Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines
D. Serum lactate greater than 4 mmol/L
E. Mean arterial pressure (MAP) of less than 65 mmHg
Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or MAP <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines, or serum lactate >4 mmol/L.
An adult client has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this client. What aspect of this care should be prioritized by the home health nurse?
A. Providing supervision to home health aides in providing necessary client care
B. Assisting the client and family to identify and mobilize community resources
C. Providing ongoing medical care during the family’s rehabilitation phase
D. Reinforcing the importance of continuous assessment with the family
B. Assisting the client and family to identify and mobilize community resources
A critical care nurse is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock?
A. Aggressive hypoglycemic control
B. Administration of hypertonic IV fluids
C. Early provision of nutritional support
D. Aggressive antibiotic therapy
C. Early provision of nutritional support
Nutritional support is necessary for all clients who are experiencing shock. Burn about 3000 calories during shock
The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body’s needs?
A. It slows the proliferation of bacteria and viruses during shock.
B. It decreases the energy expended through the functioning of the GI system.
C. It assists in expanding the intravascular volume of the body.
D. It promotes GI function through direct exposure to nutrients.
D. It promotes GI function through direct exposure to nutrients.
al or enteral nutritional support should be initiated as soon as
possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feeding.
The intensive care unit nurse is caring for an acutely ill client with signs of multiple organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing MODS due to all of the following EXCEPT:
A. Malnutrition
B. Advanced age
C. Multiple comorbidities
D. Progressive dyspnea
D. Progressive dyspnea
The client with advanced age is at risk for developing MODS due to the lack of physiological reserve. The client with malnutrition metabolic compromise and the client with multiple comorbidities is at risk for developing MODS due to decreased organ function. Progressive dyspnea is the first sign of MODS.
A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply.
A. Hypovolemia
B. Difficulty breathing
C. Cardiovascular overload
D. Pulmonary edema
E. Hypoglycemia
B. Difficulty breathing
C. Cardiovascular overload
D. Pulmonary edema
Complications of Fluid replacement: the nurse monitors the client closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema.
The intensive care unit nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of:
A. increased stroke volume.
B. increased cardiac output.
C. decreased heart rate.
D. decreased venous return.
D. decreased venous return.
Pooling of blood in the periphery results in decreased venous return.
Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the
demands of the body.
A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses
identify? Select all that apply.
A. Anaphylactic
B. Hypovolemic
C. Cardiogenic
D. Septic
E. Neurogenic
A. Anaphylactic
D. Septic
E. Neurogenic
The varied mechanisms leading to the initial ‘vasodilation’ in distributive shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock.
A triage nurse in the emergency department (ED) is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while they were waiting for the child’s parent to get off work. Rapid onset of which condition would lead the nurse to suspect that the child is experiencing anaphylactic shock?
A. Acute hypertension
B. Respiratory distress
C. Neurologic compensation
D. Cardiac arrest
B. Respiratory distress
Characteristics of severe anaphylaxis usually include rapid onset of
hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur later if prompt treatment is not provided.
The ICU nurse is caring for a client in neurogenic shock following an overdose of antianxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?
A. Hypertension
B. Cool, moist skin
C. Bradycardia
D. Signs of sympathetic stimulation
C. Bradycardia
In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, hypotension with
bradycardia.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify?
A. Absence of infarcts or emboli
B. Reduced stroke volume and cardiac output
C. Absence of pulmonary and peripheral edema
D. Maintenance of adequate mean arterial pressure
D. Maintenance of adequate mean arterial pressure
Vasoactive medications can be given in all forms of shock to improve the client’s hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction.
The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way?
A. Through a central venous line
B. By a gravity infusion IV set
C. By IV push for rapid onset of action
D. Mixed with parenteral feedings to balance osmosis
A. Through a central venous line
Whenever possible, vasoactive medications should be given through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately.
The ICU nurse is caring for a client in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the client?
A. Anaphylaxis
B. Decreased oxygen consumption
C. Abdominal compartment syndrome
D. Decreased serum osmolality
C. Abdominal compartment syndrome
Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are given.
The intensive care unit nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring?
A. Urinary output increases
B. Skin becomes warm and dry
C. Adventitious lung sounds occur in the upper airway
D. Heart and respiratory rates are elevated
D. Heart and respiratory rates are elevated
As sepsis progresses, tissues become less perfused and acidotic. The blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g.,acute kidney injury, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the BP drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields.
An 11-year-old client has been brought to the emergency department by their parent, who reports that the client may be having a “really bad allergic reaction to peanuts” after trading lunches with a peer. The triage nurse’s rapid assessment reveals
the presence of respiratory and cardiac arrest. Which interventions should the nurse prioritize?
A. Establishing central venous access and beginning fluid resuscitation
B. Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
C. Establishing peripheral intravenous (IV) access and administering IV epinephrine
D. Performing a comprehensive assessment and initiating rapid fluid replacement
B. Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. A patent airway is also an immediate priority.
A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client’s care?
A. Communicate clearly and frequently with the client’s family.
B. Taper down interventions slowly when the prognosis worsens.
C. Transfer the client to a subacute unit when recovery appears unlikely.
D. Ask the client’s family how they would prefer treatment to proceed.
A. Communicate clearly and frequently with the client’s family.
As it becomes obvious that the client is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided throughout the client’s care for the family to see, touch, and talk to the client.
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client’s plan of care while the client is ventilated?
A. Performing frequent oral care
B. Maintaining the client in a supine position
C. Suctioning the client every 15 minutes unless contraindicated
D. Administering prophylactic antibiotics, as prescribed
A. Performing frequent oral care
Nursing interventions that reduce the incidence of VAP must also be
implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client’s mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by referring to what laboratory findings? Select all that apply.
A. Blood urea nitrogen (BUN) level
B. Urine specific gravity
C. Alkaline phosphatase level
D. Creatinine level
E. Serum albumin level
A. Blood urea nitrogen (BUN) level
B. Urine specific gravity
D. Creatinine level
Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acid–base imbalances, and a loss of the renal–hormonal regulation of BP. Urine specific gravity is also affected.
Alkaline phosphatase and albumin levels are related to hepatic function.
An immunocompromised 65-year-old client has developed a urinary tract infection, and the care team recognizes the need to prevent an exacerbation of the client’s infection that could result in urosepsis and septic shock. Which action should the nurse perform to
reduce the client’s risk of septic shock?
A. Apply an antibiotic ointment to the client’s mucous membranes, as prescribed.
B. Perform passive range-of-motion exercises unless contraindicated.
C. Initiate total parenteral nutrition (TPN).
D. Remove invasive devices as soon as they are no longer needed.
D. Remove invasive devices as soon as they are no longer needed.
Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed.
The nurse, a member of the health care team in the ED, is caring for a patient who isdetermined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention?
A)Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock.
B)Inform the patients family immediately that the patient will likely not survive to allow the family time to make plans and move forward.
C)Closely monitor fluid replacement therapy, and inform the family that the patient will probably survive and return to normal life.
D)Protect the patients airway, optimize intravascular volume, and initiate the early rehabilitation process
A)Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock.
The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention.
The nurse in the ED is caring for a patient recently admitted with a likely myocardialinfarction. The nurse understands that the patients heart is pumping an inadequatesupply of oxygen to the tissues. For what health problem should the nurse assess?
A)Dysrhythmias
B)Increase in blood pressure
C)Increase in heart rate
D)Decrease in oxygen demands
A)Dysrhythmias
Cardiogenic shock occurs when the hearts ability to pump blood is impaired and thesupply of oxygen is inadequate for the heart and tissues. Symptoms of cardiogenicshock include angina pain and dysrhythmias
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?
A. Hypovolemic
B.Circulatory (distributive)
C. Carcinogenic
D. Obstructive
B.Circulatory (distributive)
Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock.
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:
A. Valvular damage.
B. Cardiomyopathies.
C. A myocardial infarction.
D. Arrhythmias.
C. A myocardial infarction.
Cardiogenic shock is seen most frequently as a result of a myocardial infarction.
What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?
A. Insert indwelling catheters for incontinent patients.
B. Administer prophylactic antibiotics for all patients at risk.
C. Have patients wear masks in the health care facility.
D. Use strict hand hygiene techniques.
D. Use strict hand hygiene techniques.
The incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques
A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:
A. NS at 60 mL/hr via an intravenous line
B. Morphine 2 mg intravenously
C. Oxygen at 2 L/min by nasal cannula
D. Dopamine (Intropin) intravenous solution
C. Oxygen at 2 L/min by nasal cannula
In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety
When vasoactive medications are administered, the nurse must monitor vital signs at least how often?
A. Hourly
B. 45 minutes
C.15 minutes
D. 30 minutes
C.15 minutes
