Shock Flashcards
The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action?
a. Creatinine 1.0 mg/dL
b. Lactate 6 mmol/L
c. Potassium 3.8 mEq/L
d. Sodium 140 mEq/L
ANS: B
Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.
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?
a. Breath sounds and capillary refill
b. Blood pressure and oral temperature
c. Oral temperature and capillary refill
d. Right atrial pressure and urine output
ANS: 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 patients 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 patients 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 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse?
a. The assessed values are within normal limits.
b. The patient is at risk for developing cardiogenic shock.
c. The patient is at risk for developing fluid volume overload.
d. The patient is at risk for developing hypovolemic shock.
ANS: 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 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?
a. Human albumin infusion
b. Hypotonic saline solution
c. Lactated Ringers bolus
d. Packed red blood cells
ANS: C
The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringers 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?
a. High pulmonary artery occlusive pressure and high cardiac output
b. High systemic vascular resistance and low cardiac output
c. Low pulmonary artery occlusive pressure and low cardiac output
d.
Low systemic vascular resistance and high cardiac output
ANS: 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?
a. Acetaminophen suppository
b. Blood cultures from two sites
c. IV antibiotic administration
d. Isotonic fluid challeng
ANS: 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. A patient admitted with abdominal pain and an elevated white blood cell count
b. A patient with a temperature of 102 F and a general dermal rash
c. A patient with a 2-day history of nausea, vomiting, and diarrhea
d. A patient with slight rectal bleeding from inflamed hemorrhoids
ANS: 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?
a. Dobutamine (Dobutrex)
b. Furosemide (Lasix)
c. Phenylephrine (Neo-Synephrine)
d. Sodium nitroprusside (Nipride)
ANS: 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.
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?
a. High pulmonary artery diastolic pressure and low cardiac output
b. Low pulmonary artery occlusive pressure and low cardiac output
c. Low systemic vascular resistance and high cardiac output
d. Normal cardiac output and low systemic vascular resistance
ANS: 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.
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?
a. The action of the machine will improve blood supply to the damaged heart.
b. The machine will beat for the damaged heart with every beat until it heals.
c. The machine will help cleanse the blood of impurities that might damage the heart.
d. The machine will remain in place until the patient is ready for a heart transplant.
ANS: 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.
A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question?
a. Infuse normal saline at 250 mL/hr.
b. Keep head of bed elevated to 30 degrees.
c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg.
d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A
The patients elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.
. A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking?
a. Increase the rate for the prescribed dopamine (Intropin) infusion.
b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion.
c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion.
d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.
ANS: D
Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR.
After receiving 1000 mL 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 the administration of
a. nitroglycerine (Tridil).
b. drotrecogin alpha (Xigris).
c. norepinephrine (Levophed).
d. sodium nitroprusside (Nipride).
ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR.
A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate
a. infusion of 5% human albumin.
b. administration of furosemide (Lasix) IV.
c. titration of an epinephrine (Adrenalin) drip.
d. administration of hydrocortisone (SoluCortef).
ANS: B
The PAWP indicates that the patients 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. Normal saline infusion would increase the PAWP further. Hydrocortisone might be used for septic or anaphylactic shock.
The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain
a. 500 mL of 5% albumin.
b. lactated Ringers solution.
c. two 14-gauge IV catheters.
d. dopamine (Intropin) infusion.
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 Ringers solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, crystalloids should be used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the initial therapy for hypovolemic shock.
