SIRS, Shock, Sepsis, & MODS Flashcards
A nurse completed an infusion of 1000mL bolus of normal saline to a client with severe sepsis. One hour later, which lab result would require the nurse’s immediate attention?
Lactate 6mmol/L (normal 0.5-2.2)
A pt w/ cardiogenic shock is being treated w/ an infusion of dobutamine. The physician’s order indicates to titrate the infusion to achieve a cardiac index of greater than or equal to 2.5L/min/m2. The nurse measures cardiac output and notes that the calculated cardiac index for your patient is 4.9L/min/m2. What is the nurse’s priority action?
Reduce the rate of dobutamine
A pt has severe sepsis w/ BP 80/50mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 101F, and a right atrial pressure of 1mm Hg. Which intervention should the nurse carry out first?
Isotonic fluid challenge
A nurse is caring for an athlete w/ possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50, HR 45beats/min, and RR 26 breaths/min. Pts skin is warm and flushed. What is the best interpretation of these findings?
Neurogenic shock
A nurse admits a pt following a motor vehicle collision. VS include BP 70/50, HR 140beats/min, RR 36breaths/min, T 101F and SpO2 95% on 3L of O2 per nasal cannula. Lab results include hemoglobin 6.0g/dL, hematocrit 20%, and K+ 4.0. Based on this assessment, what is most important for the nurse to include in the pts plan of care?
insertion of an 18-gauge peripheral intravenous line
Which pt in the ED is the most at risk for developing hypovolemic shock?
A pt w/ a 2-day history of N/V and diarrhea
Identify the priority interventions for managing symptoms of an acute MI in the ED
Admin. nitroglycerin, O2 therapy, admin. morphine
Which nursing interventions would be appropriate after angioplasty?
Assess pedal pulses on the involved limb q 15min for 1-2 hours
A pt presents to the ED with chest pain that they have had for the past 2hrs. The pt is nauseated and diaphoretic with dusky skin color. The ECG shows ST elevation in leads ll, lll, and aVF. Which therapeutic intervention would the nurse question as potentially inappropriate?
permanent pacemaker insertion.
What medication classification would a nurse anticipate a provider would prescribe for a pt with hyperlipidemia?
HMG-CoA reductase inhibitors (statins)
A pt is having a stent placed and asks a nurse why it is necessary after having an angioplasty. Which response by the nurse is best?
“The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again.”
A pt is admitted with an acute myocardial infarction. A nurse knows that an ACE inhibitor should be started w/in 24hrs to reduce the incidence of which process?
Myocardial remodeling
A nurse is providing care to a pt who is on fibrinolytic therapy. What statement from the pt warrants further assessment and intervention by the critical care nurse?
I have an incredible headache
A pt is having a cardiac evaluation to assess for possible valvular fx and measure the size of the cardiac chambers
Echocardiogram
A nurse is caring for a client in the ED who came in via ambulance after a severe motor vehicle accident. Suddenly, the client shouts with difficulty, “Awe! I have severe chest pain that goes around to my back! Please help me!” What type of aneurysm would the nurse anticipate to cause this symptom?
Dissecting Aneurysm
