Shock & Hemodynamics Flashcards
A patient is admitted to the emergency department with severe burn injuries. The nurse’s priority actions are to prevent development of which type of shock?
- Cardiogenic
- Hypovolemic
- Distributive
- Obstructive
Correct Answer: 2
Rationale 1: Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock.
Rationale 2: Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority.
Rationale 3: Distributive shock, particularly septic shock, is a potential complication for patients with burn injury and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care.
Rationale 4: Depending upon other injuries the patient with burns may develop obstructive shock, but this is not the nurse’s highest priority in emergent care.
The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment the nurse notes that the patient’s afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis?
- Decreased circulating volume
- Reaction to antibiotics used to treat sepsis
- Marked vasodilation
- Decreased ventricular contractility
Correct Answer: 3
Rationale 1: Hemodynamic changes associated with sepsis are not caused by low circulating volume.
Rationale 2: The primary reason for decreased vascular resistance is not related to reaction to medications.
Rationale 3: Sepsis, through its release of inflammatory mediators, causes vasodilation, resulting in the markedly low systemic vascular resistance.
Rationale 4: Ventricular contractility may be reduced following the release of myocardial depressant factor as a result of sepsis. However, this is not the primary cause of decreased vascular resistance.
A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive?
- The patient complains of a severe headache.
- The patient’s urine output has dropped.
- The patient begins to shiver.
- The patient develops a cough.
Correct Answer: 3
Rationale 1: Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia.
Rationale 2: Decreased urine output is not associated with treatment for hyperthermia.
Rationale 3: Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified.
Rationale 4: Development of a cough is not associated with treatment for hyperthermia.
A patient, with a steadily increasing preload, was experiencing a corresponding increase in stroke volume but it has now begun to decrease. Which rationale would the nurse provide for this occurrence?
- This fluctuation will occur until maximum preload has been reached.
- The patient’s heart rate is increasing, which causes a drop in stroke volume.
- The patient’s preload has reached a critical point and now stroke volume will decrease.
- It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease.
Correct Answer: 3
Rationale 1: There is a point of maximum preload, but the cardiac output does not fluctuate until it is reached.
Rationale 2: The information in this question does not support increase in the heart rate.
Rationale 3: Until a critical point is reached, as preload increases, so does stroke volume. An optimal preload leads to an optimal stroke volume. Once past this point, an increase in preload results in a decrease in stroke volume. If the heart receives too much preload, it cannot effectively pump out that volume and stroke volume decreases. Stroke volume decreases because too much volume causes excessive stretching of the myocardial fibers and the ventricles cannot effectively contract.
Rationale 4: There is no need to look for a different pathophysiological event as the event at present is sufficient to cause decrease in cardiac output.
A patient is admitted with the complaint of chest pain. Questions about which history will best help the nurse determine if the pain is from cardiac or pulmonary origin?
- Deficits in movement, timing of the pain, and dietary changes in the last 24 hours
- What precipitated the pain, what it feels like, and where it is located
- Changes in dietary habits, smoking history, and presence of cough
- What home remedies were tried, activity level, and fluid intake changes
Correct Answer: 2
Rationale 1: Deficits in movement, timing of the pain, and dietary changes in the last 24 hours are not associated with either cardiac or pulmonary pain.
Rationale 2: Precipitating factors, quality, and location will help the health care team discriminate between pain of cardiac origin and pain of respiratory origin.
Rationale 3: This is important information to obtain, but would not help differentiate between pain of cardiac origin and pain of respiratory origin.
Rationale 4: This is important information, but will not help to differentiate between pain of cardiac origin and pain of respiratory origin.
A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate?
- Decreasing the amount of oxygen being given
- Immediate initiation of fluid resuscitation
- Repeat of the testing in 4 hours
- Bedside fingerstick level of blood glucose
Correct Answer: 2
Rationale 1: An increased serum lactate calls for increased oxygenation.
Rationale 2: A lactate level of 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation.
Rationale 3: There is no need to repeat this test before intervening.
Rationale 4: Measuring blood glucose is not indicated by this lab result.
The nurse is caring for a patient who is being monitored with a pulmonary artery catheter. Which change requires immediate intervention?
- Systemic vascular resistance of 900 dynes/sec/cm5
- Appearance of an “a” wave on the pulmonary artery waveform
- Pulmonary artery wedge pressure of 10 mm Hg
- Spontaneous development of a pulmonary artery wedge pressure waveform
Correct Answer: 4
Rationale 1: A systemic vascular resistance of 900 is normal.
Rationale 2: The “a” wave is indicative of the rise in atrial pressure produced by left atrial contraction and is normal.
Rationale 3: A pulmonary arterial wedge pressure of 10 mm Hg is within normal limits.
Rationale 4: A permanent wedge waveform is an indication of catheter migration further into the pulmonary artery causing occlusion. Immediate intervention is needed to prevent pulmonary infarction.
Which assessment techniques will the nurse use to evaluate the patient’s cardiac output? Select all that apply
- Inspection of color changes in the periphery
- Strength of pulses
- Percussion of heart borders
- Auscultation of heart sounds
- Pulse pressure determination
Correct Answer: 1,2,4,5
Rationale 1: Color changes in the periphery can indicate decreased cardiac output.
Rationale 2: Strength of pulse is an indirect measure of cardiac output and contractility.
Rationale 3: Percussion is incorrect because it measures heart size very crudely but not output.
Rationale 4: Auscultation helps the nurse assess heart rate and rhythm which can alter cardiac output.
Rationale 5: Determination of pulse pressure is an indirect measure of stroke volume which is a component of cardiac output.
A patient is admitted with a decrease in cardiac output. Which assessment findings would the nurse attribute to that condition?
- Increased output of very clear urine
- Changes in skin color
- Localized edema in the calf
- Skin that is warm and damp
Correct Answer: 2
Rationale 1: A decrease in cardiac output generally results in a decrease in urine output.
Rationale 2: Changes in skin color can be a sign of hemodynamic compromise and a decrease in cardiac output.
Rationale 3: Localized edema in the calf is indicative of obstruction of venous blood flow from a clot in a leg vein.
Rationale 4: Cool skin is a finding associated with decreased cardiac output.
A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock?
- Cold extremities
- Increase in serum lactate levels
- Decreased SCVO2
- Widening of pulse pressure
Correct Answer: 4
Rationale 1: Cold and mottled extremities are associated with later stages of septic shock.
Rationale 2: Increased serum lactate levels indicate a later stage of shock.
Rationale 3: Decreased SCVO2 indicates a later stage of shock.
Rationale 4: Since the patient’s diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock
A patient is being prepared for impedance cardiography. Which information will the nurse provide?
- “This technology will use ultrasound to measure your heart rate and blood flow.”
- “We are preparing to measure the oxygenation of your peripheral tissues.”
- “A catheter will be inserted into a vein in your neck.”
- “Electrodes will be placed on your neck and your lateral chest.”
Correct Answer: 4
Rationale 1: Doppler technology uses ultrasound through a probe to measure heart rate and blood flow.
Rationale 2: Pulse oximetry is used to measure peripheral oxygenation of tissues.
Rationale 3: Cannulation of the right subclavian or internal jugular vein is necessary for placement of a central venous catheter.
Rationale 4: Impedance cardiography is used to assess cardiac function through the use of a high-frequency, low-amplitude current to measure the resistance to flow of the electrical current. The procedure includes placing electrodes bilaterally at the base of the neck and on the lateral chest at the level of the diaphragm.
A patient who sustained a gunshot wound walks into the emergency department and collapses. Which priority directions should the nurse who assumes this patient’s care give to those coming to assist? Select all that apply.
- Check the airway.
- Bring a wheelchair.
- Put direct pressure on the leg wound.
- Check for identification.
- Check the pulse.
Correct Answer: 1,3,5
Rationale 1: Airway patency is the most important intervention for this patient.
Rationale 2: This patient will likely need to be transported by stretcher.
Rationale 3: Controlling the source of the fluid loss is imperative.
Rationale 4: Checking for identification can wait until more pertinent interventions are performed.
Rationale 5: The patient may have collapsed due to cardiac arrest from hypovolemia. Checking the pulse is part of the immediate assessment.
The nurse is caring for a patient having a transesophageal echocardiogram (TEE). What is an appropriate nursing intervention for the care of this patient?
- Dim the lights in the room.
- Monitor for bradycardia and hypotension.
- Assess pedal pulses bilaterally.
- Apply pressure to the puncture site.
Correct Answer: 2
Rationale 1: There is no specific reason to dim the room lights.
Rationale 2: The TEE is done under conscious sedation. During and immediately after the procedure, the nurse assesses for bradycardia and hypotension because of possible stimulation of the patient’s vagus nerve.
Rationale 3: There is no specific indication that assessing pedal pulses is necessary during this procedure.
Rationale 4: There is no puncture site in a TEE.
A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic?
- The amount of blood the heart pumps every minute
- The strength of the heartbeat
- The amount of resistance the heart beats against
- The amount of blood in the heart before it beats
Correct Answer: 2
Rationale 1: The amount of blood the heart pumps every minute is the cardiac output. Ejection fraction is related to cardiac output, but describing cardiac output does not fully explain ejection fraction.
Rationale 2: Contractility is defined as the force of myocardial contraction and reflects the ability of the heart muscle to work independently of preload and afterload; the ability to function as a pump. Ejection fraction is a measure of the percent of blood ejected with each stroke volume and is used as an index of myocardial function.
Rationale 3: Afterload is the amount of resistance the heart must beat against. Increasing afterload will affect both ejection fraction and cardiac output.
Rationale 4: Preload represents the volume of blood in the ventricle at the end of diastole. A low preload can result in low cardiac output and may also affect ejection fraction.
Which nursing interventions are indicated when measuring pulmonary artery wedge pressure (PAWP)? Select all that apply.
- Use no more than 1.25 mL of air to inflate the balloon.
- Pull back on the syringe to deflate the balloon.
- Leave the balloon slightly inflated to maintain integrity.
- Maintain balloon inflation for 3 to 5 minutes to obtain a stable reading.
- If there is any resistance during inflation do not continue.
Correct Answer: 1,5
Rationale 1: Using the smallest inflation volume possible, typically less than 1.25 mL, reduces the risk of balloon rupture.
Rationale 2: Passive deflation should be used to avoid damage to the balloon.
Rationale 3: The balloon should be completely deflated to avoid a continuous wedge, which could lead to pulmonary infarction.
Rationale 4: The balloon should be inflated only long enough to obtain a stable reading.
Rationale 5: Resistance may indicate that the balloon is compromising the artery. The nurse should stop inflation, allow the balloon to passively deflate and call the health care provider.
The preceptor nurse is assisting a newly hired nurse with completion of hemodynamic assessment using a pulmonary artery catheter. Which action would require the preceptor to intervene?
- Inflating the pressure bag to 300 mm Hg
- Infusing a vasoactive drug through the proximal injectate port
- Obtaining a pulmonary artery wedge pressure reading through the distal port
- Using iced normal saline to obtain a cardiac output
Correct Answer: 2
Rationale 1: In order to overcome arterial pressure and prevent blood from backing up into the pressure tubing, the pressure bag placed around the flush solution should be inflated to 300 mm Hg.
Rationale 2: The proximal injectate port is the primary port used for obtaining cardiac output via boluses of iced or room temperature normal saline. Because of the risk of inadvertent bolus of potent medications, neither vasopressor nor vasodilators should be administered through the same port used for obtaining cardiac output. It would be safer to infuse vasoactive drugs through the proximal infusion port.
Rationale 3: The distal port is the designated port for continuous monitoring of the pulmonary artery pressure and for obtaining the pulmonary artery wedge pressure.
Rationale 4: Either iced or room temperature normal saline can effectively be used to obtain accurate cardiac output measurements.
A patient who has a pulmonary artery catheter in place is to receive the drug nitroprusside. The nurse would assess for which indicator of the drug’s effectiveness?
- Decreased systemic vascular resistance
- Decreased cardiac output
- Increased right atrial pressure
- Increased pulmonary artery wedge pressure
Correct Answer: 1
Rationale 1: Nitroprusside is a potent systemic vasodilator with primary action on decreasing afterload, which is measured by systemic vascular resistance.
Rationale 2: Nitroprusside should decrease cardiac workload and increase stroke volume which will increase cardiac output.
Rationale 3: Nitroprusside administration should result in right atrial pressure decrease.
Rationale 4: Pulmonary artery wedge pressure should decrease.
A patient is scheduled for an exercise electrocardiogram. The nurse will ensure that which objects are in the room prior to the beginning of the test?
- Oral fluids
- A defibrillator
- External pacemaker
- Portable chest x-ray machine
Correct Answer: 2
Rationale 1: There is no reason that oral fluids are required for this test.
Rationale 2: Emergency medications and a defibrillator should be present in the room during an exercise electrocardiogram test. The patient may respond poorly to the stress placed on the heart during exercise and may require an emergency response with this equipment.
Rationale 3: There is no specific indication that it is necessary to have an external pacemaker present when this testing is taking place.
Rationale 4: There is no reason for a portable x-ray machine to be present in the room during this test.
A patient with congestive heart failure is receiving scheduled doses of an intravenous diuretic. After administering the drug, which finding would indicate to the nurse that the drug was effective?
- A pulmonary artery wedge pressure of 16 mm Hg
- Pulmonary artery pressure of 34/16 mm Hg
- Systemic vascular resistance of 1,400 dynes/sec/cm-5
- A right atrial pressure of 5 mm Hg
Correct Answer: 4
Rationale 1: Normal pulmonary arterial wedge pressure is 4 to 12; 16 is high and would indicate high preload.
Rationale 2: Normal pulmonary artery pressure is 20 to 30 mm Hg/8 to 15 mm Hg. These pressures should decrease with diuretic administration.
Rationale 3: Normal systemic vascular resistance is 800 to 1,200 dynes/sec/cm-5. With diuretic use, the systemic vascular resistance should also normalize.
Rationale 4: A right atrial pressure of 5 is a normal reading and would indicate the diuretic is having its intended effect.
A patient who has a radial artery catheter in place is complaining of numbness and tingling in the fingers. What is the nurse’s priority assessment?
- Is there a palpable pulse?
- Is blood is easily obtained from the catheter?
- Does the patient have a fever?
- Does the waveform have a characteristic appearance?
Correct Answer: 1
Rationale 1: Monitoring circulation distal to the arterial insertion site is the priority nursing function. Skin color and temperature and all pulses should be regularly assessed and documented.
Rationale 2: It is important to be able to easily access blood from the catheter, but this is not the priority assessment.
Rationale 3: Fever might indicate an infection at the insertion site, but if this is occurring it will take time to treat. This is a very important assessment, but is not the highest priority.
Rationale 4: An appropriate and normal waveform is an assurance that the system is functioning and measurements would be accurate. However, this is not the most important for the patient’s safety and prevention of complications.
A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy? Select all that apply.
- Persistent hypotension
- Heart rate 118
- Development of a bundle branch block
- Drop in urine output
- Mottling of extremities
Correct Answer: 2,3,4,5
Rationale 1: The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring.
Rationale 2: Tachycardia can be an adverse effect of dopamine.
Rationale 3: Aberrant cardiac conduction may indicate an adverse drug effect is occurring.
Rationale 4: Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidney will cause decrease in urine output.
Rationale 5: Mottling of extremities indicates peripheral ischemia.
A patient’s cardiac index will be calculated. What nursing interventions are necessary before this calculation is completed? Select all that apply.
Standard Text: Select all that apply.
- Assure that there is an accurate current weight on the medical record.
- Compare fluid input and output for the last 12 hours.
- Measure the patient’s height.
- Figure the patient’s age in years and months.
- Obtain the patient’s current heart rate.
Correct Answer: 1,3,5
Rationale 1: Weight is a component of cardiac index.
Rationale 2: There is no need to compare fluid intake and output in order to calculate cardiac index.
Rationale 3: Height is used to calculate cardiac index.
Rationale 4: Age is not a consideration when calculating cardiac index.
Rationale 5: Heart rate is a component of cardiac index.