Exam 2 Flashcards
Cardiomyopathy and Shock
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. The health care provider would ideally use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?
A. Unstable angina pectoris
B. Aortic insufficiency
C. Hypertension
D. Diabetes mellitus
B. Aortic insufficiency
A history of aortic insufficiency contraindicates the use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn’t respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren’t contraindications for IABP.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. The nurse knows that vasoactive medicines are given in all forms of shock. What is the primary goal of this aspect of treatment?
A. To prevent the formation of infarcts of emboli
B. To limit stroke volume and cardiac output
C. To avoid pulmonary and peripheral edema
D. To maintain adequate mean arterial pressure (MAP)
D. To maintain adequate mean arterial pressure (MAP)
Vasoactive medications can be administered in all forms of shock to improve the client’s hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.
A client with profuse bleeding from an abdominal gunshot wound is brought in for emergency care. Place the actions the nurse should take in order. All options must be used.
1. Assess vital signs and oxygen saturation. 2. Infuse intravenous fluids. 3. Assess the body for other injuries. 4. Control the pain from the injury. 5. Maintain NPO in anticipation of surgery.
- Assess vital signs and oxygen saturation.
- Infuse intravenous fluids.
- Assess the body for other injuries.
- Control the pain from the injury.
- Maintain NPO in anticipation of surgery.
Monitoring a client in the acute phase of care is best reflected by monitoring the ABCs (airway, breathing, circulation). The top priority is to assess vital signs and oxygen saturation (airway, breathing, circulation) followed by intravenous fluids to prevent shock (circulation). Further assessment for injuries (as the first step of the nursing process) would be completed next, followed by pain control. (Pain is the sixth vital sign). Maintaining NPO status in anticipation of surgery is important, but stabilization of the client is the priority.
The health care provider prescribes a vasoactive agent for a client in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?
A. Levophed
B. Dobutrex
C. Nipride
D. Methotrexate
A. Levophed
The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.
The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following?
A. Low B. High C. Normal D. Unable to measure
A. Low
The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.
The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.
A. 60 mm Hg
B. 70 mm Hg
C. 80 mm Hg
D. 90 mm Hg
A. 60 mm Hg
Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.
The nurse reviews the diagnostic lab work of a client who is developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?
A. Hemoglobin: 14.2 g/dL
B. Potassium: 4.8 mEq/L
C. WBC: 42,000/mm3
D. ESR: 19 mm/hour
C. WBC: 42,000/mm3
Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.
When beta-2 adrenergic receptors are stimulated, which of the following occur?
A. Bronchioles relax
B. Vasoconstriction in heart
C. Vasoconstriction in skeletal muscles
D. Bronchioles constrict
A. Bronchioles relax
When beta-2 adrenergic receptors are stimulated, vasodilation occurs in the heart and skeletal muscles, and the bronchioles relax,
Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for clients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:
A. Blood pressure.
B. Breath sounds.
C. Renal output.
D. Heart rate.
A. Blood pressure.
By the time the blood pressure drops, damage has already occurred at the cellular and tissue levels. Therefore, the client at risk for shock must be monitored closely before the blood pressure drops.
Morphine sulfate has which of the following effects on the body?
A. Reduces preload B. Increases preload C. Increases afterload D. No effect on preload or afterload
A. Reduces preload
In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). So it reduces preload AND afterload.
A nurse is caring for a postoperative client. What intervention(s) will help prevent thrombophlebitis?
Select all that apply.
A. Leg range of motion exercises
B. Sequential compression devices (SCDs) and antiembolic stockings
C. Early ambulation as tolerated
D. Frequent turning and positioning
E. Leg exercises using light ankle weights
F. Deep breathing and coughing exercises
A. Leg range of motion exercises
B. Sequential compression devices (SCDs) and antiembolic stockings
C. Early ambulation as tolerated
D. Frequent turning and positioning
During surgery, venous blood return from the legs slows; in addition, some surgical positions decrease venous return. Thrombophlebitis and resultant emboli are potential complications from this circulatory stasis in the legs. Leg exercises, frequent turning and positioning, the use of SCDs and antiembolic stockings, adequate hydration, early ambulation, and anticoagulant prophylaxis increase venous return. Deep breathing and coughing improve postoperative gas exchange and prevent respiratory complications such as atelectasis. Using weights would not help prevent thrombophlebitis.
A client with a gastrointestinal bleed has vomited 600 mL of frank red blood and is now pale and diaphoretic. Place in order the steps of care the nurse should provide to the client. All options must be used.
1. Assess for a patent airway and circulation. 2. Measure vital signs and oxygen saturation level. 3. Initiate IV access with large-bore catheters. 4. Notify the health care provider. 5. Assist with emergency care.
As listed: 1, 2, 3, 4, 5.
The nurse determines that a client in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?
A. Increase in diastolic pressure
B. Decrease in respiratory rate
C. Increase in systolic blood pressure
D. Narrowed pulse pressure
D. Narrowed pulse pressure
Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.
A client is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?
A. Pericardiocentesis
B. Thoracotomy with chest tube insertion
C. Administration of oxygen via venture mask
D. Intubation and mechanical ventilation
D. Intubation and mechanical ventilation
Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Pericardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.
The nurse is caring for a child. Upon assessing the child, the nurse notes a heart rate of 235, abnormal P waves, weak peripheral pulses, and a decreased level of consciousness. The nurse is aware that this child is presenting in which cardiac arrhythmia?
A. compensated SVT
B. uncompensated SVT
C. ventricular tachycardia
D. ventricular fibrillation
B. uncompensated SVT
Signs and symptoms for uncompensated supraventricular tachycardia include a heart rate >220 bpm, abnormal P waves, and signs of shock such as altered level of consciousness, poor perfusion, and weak pulses.
Compensated SVT signs and symptoms include a heart rate of >220 with an alert, well-perfused child. Ventricular tachycardia includes wide QRS complexes with no P waves, with or without a pulse. Ventricular fibrillation signs and symptoms include chaotic ventricular activity with no P, QRS, or T waves present.
The nurse plans to educate the parents of a child experiencing septic shock about the purpose of administering dobutamine intravenously to their child. What would the nurse include in this educational plan?
A. Dobutamine is used to improve cardiac contractility.
B. Dobutamine will work to eliminate the bacteria causing the infection.
C. Dobutamine is used to provide vasodilation, thus increasing blood pressure.
D. Dobutamine will work to dry secretions and inhibit serotonin and histamine.
A. Dobutamine is used to improve cardiac contractility.
Dobutamine improves the contractility of the heart muscle during shock. The medication is not an antibiotic. Vasodilation would result in lower blood pressure. Atropine (anticholinergic) increases cardiac output, dries secretions, and inhibits serotonin and histamine.
A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has “shock.” What are the etiologies of shock? Select all that apply.
A. heart fails as effective pump
B. blood volume decreases
C. peripheral vascular dilation
D. blunt force trauma
E. nausea
A. heart fails as effective pump
B. blood volume decreases
C. peripheral vascular dilation
Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock develops as a consequence of one of three events: (1) blood volume decreases, (2) the heart fails as an effective pump, or (3) peripheral blood vessels massively dilate (Wedro, 2014).
The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?
A. 0.9% sodium chloride
B. Lactated Ringer’s
C. Albumin
D. Dextran
B. Lactated Ringer’s
Lactated Ringer’s is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.
A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?
A. Increasing heart rate
B. Pale, warm, dry skin
C. Heart rate of 70 beats/minute
D. Elevated blood pressure
A. Increasing heart rate
Early in shock, heart rate increases. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client’s heart rate will become elevated above normal. In early shock the client’s blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.
Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation? Select all that apply.
A. Acid–base imbalance
B. Increased capillary permeability and fluid and electrolyte shifts
C. Increased blood urea nitrogen and serum creatinine
D. A mean arterial blood pressure of 70 mm Hg
E. Bradycardia with a heart rate of 60 beats/min
A. Acid–base imbalance
B. Increased capillary permeability and fluid and electrolyte shifts
C. Increased blood urea nitrogen and serum creatinine
In decompensation, the MAP would be less than 65 mm Hg, and the heart rate would be tachycardic or erratic with instances of asystole.
What is the major clinical use of dobutamine?
A. increase cardiac output.
B. prevent sinus bradycardia.
C. treat hypotension.
D. treat hypertension.
A. increase cardiac output.
Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Health care providers may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Health care providers use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don’t use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as
A. Sodium nitroprusside
B. Norepinephrine
C. Dopamine
D. Furosemide
A. Sodium nitroprusside
Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.
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
In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client’s skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine 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. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. The 3% NaCl is a hypertonic solution and is not isotonic.
