Chapter 11
Chapter 11
Chapter 11
3. A primary goal in all shock states is to: B.maintain adequate tissue perfu-
A.ensure adequate cellular hydration. sion.
B.maintain adequate tissue perfusion. Care of a patient in shock is di-
C.prevent third spacing of fluids. rected toward correcting or revers-
D.support mechanical ventilation. ing the altered circulatory compo-
nent and reversing tissue hypoxia.
Restoring circulating intravascular
volume is the priority in improving
tissue perfusion and oxygen deliv-
ery.
6. Blood pooling in the capillary bed and D.multisystem organ failure and/or
arterial blood pressure too low to sup- dysfunction.
port perfusion of vital organs cause: Maldistribution of blood flow refers
A.acute respiratory distress syndrome to the uneven distribution of flow
(ARDS). to various organs and pooling of
B.disseminated intravascular coagula- blood in the capillary beds. This im-
tion (DIC). paired blood flow leads to impaired
C.increased cerebral perfusion pres- tissue perfusion and a decreased
sure. oxygen supply to the cells, all of
D.multisystem organ failure and/or which contribute to multiple organ
dysfunction. failure. Damage to the type II pneu-
mocytes leads to ARDS. Consump-
tion of clotting factors may cause
DIC. Low arterial blood pressure
leads to decreased cerebral perfu-
sion pressure.
7. The nurse is caring for a patient ad- A.Central venous pressure > 8 mm
mitted with severe sepsis. The physi- Hg
cian orders include the administration Early goal-directed therapy in-
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of large volumes of isotonic saline so- cludes administration of IV fluids
lution as part of early goal-directed to keep the central venous pres-
therapy. Which of the following best sure at 8 mm Hg or greater. Ad-
represents a therapeutic endpoint for ditional therapeutic endpoints in-
goal-directed fluid therapy? clude a heart rate at less than
A.Central venous pressure > 8 mm Hg 110 beats per minute and a mean
B.Heart rate > 60 beats/min arterial blood pressure at 65 mm
C.Mean arterial pressure > 50 mm Hg Hg or greater. Serum lactate levels
D.Serum lactate level > 6 mEq/L are elevated in sepsis; target levels
should be < 2.2 mEq/L.
9. Which statement correctly represents B.High heart rate; low right atrial
hemodynamic values associated with pressure
the initial stages of septic shock state? In septic shock, inflammatory medi-
A.Low heart rate; high blood pressure ators damage the endothelial cells
B.High heart rate; low right atrial pres- that line blood vessels, produc-
sure ing profound vasodilation and in-
C.High PAOP; low cardiac output creased capillary permeability. Ini-
D.High SVR; normal blood pressure tially this results in a high heart
rate, hypotension, and low SVR,
and subsequently in low right atrial
pressure.
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12. Large volume crystalloid solution to C.Lactated Ringer's (LR)
treat hypovolemia can be accom- D.Normal saline
plished with which of the following in- LR solution and 0.9% normal saline
fusions? (Select all that apply.) are isotonic solutions that are com-
A.5% dextrose monly infused to treat hypovolemia.
B.Albumin Solutions of 5% dextrose in wa-
C.Lactated Ringer's (LR) ter and 0.45% normal saline are
D.Normal saline hypotonic and are not used for
fluid resuscitation. Hypotonic solu-
tions rapidly leave the intravascu-
lar space, causing interstitial and
intracellular edema. A systematic
review of 30 randomized controlled
trials found no benefit in giving
colloids (e.g., albumin) over crys-
talloids and recommended against
the administration of colloids in
most patient populations
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C. brain injuries.
D. burn injuries.
28. Anaphylactic shock manifests with the B. Dyspnea, hypotension, and ur-
rapid onset of which set of symp- ticaria
toms?
A. Bradycardia, decreased arterial
pressure, and oliguria
B. Dyspnea, hypotension, and ur-
ticaria
C. Hypertension, anxiety, and tachy-
cardia
D. Fever, hypotension, and erythema-
tous rash
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36. In MODS, which of the following events D. All of the above
contribute to organ failure?
A. Microvascular clotting
B. Interstitial edema
C. Exhaustion of fuel supply
D. All of the above
38. All of the following alterations would D. increased serum urea levels.
indicate that a patient is developing
liver failure in MODS except:
A. increased serum ammonia levels.
B. jaundice.
C. increased levels of liver enzymes.
D. increased serum urea levels.
39. Which burn injury involves most of the C. Deep partial thickness (second
dermis and leaves only a few epider- degree)
mal appendages intact?
A. First degree
B. Superficial partial thickness (sec-
ond degree)
C. Deep partial thickness (second de-
gree)
D. Third degree
42. During the first 24 hours after a se- A. Increased capillary permeability
vere burn injury, which of the follow-
ing physiologic responses typically
occurs?
A. Increased capillary permeability
B. Inhibition of stress hormone re-
lease
C. Increased cardiac contractility and
cardiac output
D. Increased peripheral vascular resis-
tance
44. Individuals with severe burns are of- C. Evaporative heat loss from major
ten at risk for becoming hypother- burn wounds can lead to hypother-
mic. Which of the following descrip- mia.
tions best characterizes the underly-
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ing cause of this problem?
A. Burn patients experience hypother-
mia as a rebound reaction from the
heat damage.
B. Burn patients tend to be hypother-
mic due to hypotension and ischemia.
C. Evaporative heat loss from major
burn wounds can lead to hypothermia.
D. Blood coagulation limits the blood
circulating to the body core, thereby
causing hypothermia.
45. Why do individuals with severe burns C. Airway edema is a common oc-
have difficulty breathing and often re- currence with severe burn injuries.
quire intubation, even if there was no
smoke inhalation causing acute lung
injury?
A. Severe pulmonary edema develops
immediately following all severe burn
injuries.
B. Pulmonary emboli typically form af-
ter severe burn injuries.
C. Airway edema is a common occur-
rence with severe burn injuries.
D. Pneumothorax and pleural effu-
sions occur with severe burn injuries.
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etiology. The first action by the nurse nurse are focused on the ABCs,
should be to and assessing the airway and ven-
a. check the blood pressure. tilation is necessary. The other
b. obtain an oxygen saturation. assessments should be accom-
c. attach a cardiac monitor. plished as rapidly as possible af-
d. check level of consciousness. ter the oxygen saturation is deter-
mined and addressed.
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diac output. During shock, fluid leaks from the
c. release of aldosterone and antid- intravascular space into the intersti-
iuretic hormone (ADH), which cause tial space.
sodium and water retention.
d. movement of interstitial fluid to the
intravascular space, increasing renal
blood flow.
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a. Insert two 14-gauge IV catheters. blood for transfusions should also
b. Administer oxygen at 100% per be rapidly accomplished, but only
non-rebreather mask. after actions to maximize oxygen
c. Place the patient on continuous car- delivery have been implemented.
diac monitor.
d. Draw blood to type and crossmatch
for transfusions.
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left-forearm IV. Which assessment in- travasation of the Neo-Synephrine.
formation obtained by the nurse indi- The nurse should discontinue the
cates a need for immediate action? IV and, if possible, infuse the med-
a. The patient has an apical pulse rate ication into a central line. An apical
of 58 beats/min. pulse of 58 is typical for neurogenic
b. The patient's urine output has been shock but does not indicate an im-
28 ml over the last hour. mediate need for nursing interven-
c. The patient's IV infusion site is cool tion. A 28-ml output over 1 hour
and pale. would require the nurse to monitor
d. The patient has warm, dry skin on the output over the next hour, but an
the extremities. immediate change in therapy is not
indicated. Warm, dry skin indicates
that the patient is in early neuro-
genic shock.
56. 10. A patient in septic shock has not re- Correct Answer: C
sponded to fluid resuscitation, as ev- Rationale: When fluid resuscitation
idenced by a decreasing BP and car- is unsuccessful, administration of
diac output. The nurse anticipates the vasopressor drugs is used to in-
administration of crease the systemic vascular re-
a. nitroglycerine (Tridil). sistance (SVR) and improve tis-
b. dobutamine (Dobutrex). sue perfusion. Nitroglycerin would
c. norepinephrine (Levophed). decrease the preload and further
d. sodium nitroprusside (Nipride). drop cardiac output and BP. Dobut-
amine will increase stroke volume,
but it would also further decrease
SVR. Nitroprusside is an arterial
vasodilator and would further de-
crease SVR.
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a. Administer all medications through for infection and sepsis. There is no
the patient's indwelling central line. indication that the patient is neu-
b. Place the patient in a private room. tropenic, and restricting the patient
c. Restrict the patient to foods that to cooked and processed foods is
have been well-cooked or processed. likely to decrease oral intake fur-
d. Insert a nasogastric (NG) tube for ther and cause further malnutrition,
enteral feeding. a risk factor for sepsis and shock.
Insertion of an NG tube is invasive
and will not decrease the patient's
nausea and vomiting.
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60. 14. The triage nurse receives a call Correct Answer: C
from a community member who is dri- Rationale: A patient with multiple
ving an unconscious friend with mul- trauma may require fluid resuscita-
tiple injuries after a motorcycle acci- tion to prevent or treat hypovolemic
dent to the hospital. The caller states shock, so the nurse will anticipate
that they will be arriving in 1 minute. the need for 2 large bore IV lines to
In preparation for the patient's arrival, administer normal saline. Lactated
the nurse will obtain Ringer's solution should be used
a. a liter of lactated Ringer's solution. cautiously and will not be ordered
b. 500 ml of 5% albumin. until the patient had been assessed
c. two 14-gauge IV catheters. for possible liver abnormalities. Al-
d. a retention catheter. though colloids may sometimes be
used for volume expansion, it is
generally accepted that crystalloids
should be used as the initial thera-
py for fluid resuscitation. A catheter
would likely be ordered, but in the 1
minute that the nurse has to obtain
supplies, the IV catheters would
take priority.
61. 15. The nurse evaluates that fluid re- Correct Answer: A
suscitation for a 70 kg patient in shock Rationale: Assessment of end-or-
is effective on finding that the patient's gan perfusion, such as an ade-
a. urine output is 40 ml over the last quate urine output, is the best in-
hour. dicator that fluid resuscitation has
b. hemoglobin is within normal limits. been successful. The hemoglobin
c. CVP has decreased. level is not useful in determining
d. mean arterial pressure (MAP) is 65 whether fluid administration has
mm Hg. been effective unless the patient is
bleeding and receiving blood. A de-
crease in CVP indicates that more
fluid is needed. The MAP is at the
low normal range, but does not
clearly indicate that tissue perfu-
sion is adequate.
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Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
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tion and sepsis. Which information ob- cation that the patient is in the pro-
tained in the assessment indicates a gressive stage of shock. The other
need for a change in therapy? data are consistent with compen-
a. The patient is restless and anxious. sated shock.
b. The patient has a heart rate of 134.
c. The patient has hypotonic bowel
sounds.
d. The patient has a temperature of
94.1° F.
64. 18. When the nurse is caring for a pa- Correct Answer: C
tient in cardiogenic shock who is re- Rationale: Because PAWP is in-
ceiving dobutamine (Dobutrex) and ni- creased in cardiogenic shock as
troglycerin (Tridil) infusions, the best a result of the increase in volume
evidence that the medications are ef- and pressure in the left ventricle,
fective is that the normalization of PAWP is the best
a. systolic BP increases to greater indicator of patient improvement.
than 100 mm Hg. The changes in BP and heart rate
b. cardiac monitor shows sinus rhythm could occur with dobutamine infu-
at 96 beats/min. sion even if patient tissue perfu-
c. PAWP drops to normal range. sion was not improved. Troponin
d. troponin and creatine kinase levels and creatine kinase (CK) levels are
decrease. indicators of cardiac cellular death
and are not used as indicators of
improved tissue perfusion.
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68. 22. A patient who has just been ad- Correct Answer: B
mitted with septic shock has a BP of Rationale: Because of the low sys-
70/46, pulse 136, respirations 32, tem- temic vascular resistance (SVR)
perature 104.0° F, and blood glucose associated with septic shock, fluid
246 mg/dl. Which order will the nurse resuscitation is the initial therapy.
accomplish first? The other actions are also appro-
a. Start insulin drip to maintain blood priate and should be initiated quick-
glucose at 110 to 150 mg/dl. ly as well.
b. Give normal saline IV at 500 ml/hr.
c. Titrate norepinephrine (Levophed)
to keep MAP at 65 to 70 mm Hg.
d. Infuse drotrecogin- (Xigris) 24
mcg/kg.
70. 24. When caring for a patient with car- Correct Answer: C
diogenic shock and possible MODS, Rationale: The elevated ammonia
which information obtained by the level and confusion suggest liver
nurse will help confirm the diagnosis failure in addition to the cardiac fail-
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Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
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of MODS? ure. The crackles, chest pain, and
a. The patient has crackles throughout cool extremities are all consistent
both lung fields. with cardiogenic shock and do not
b. The patient complains of 8/10 crush- indicate that there are failures in
ing chest pain. other major organ systems.
c. The patient has an elevated ammo-
nia level and confusion.
d. The patient has cool extremities and
weak pedal pulses.
73. 27. When caring for a patient who has Correct Answer: C
just been admitted with septic shock, Rationale: The best data for as-
which of these assessment data will be sessing the adequacy of cardiac
of greatest concern to the nurse? output are those that provide infor-
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a. BP 88/56 mm Hg mation about end-organ perfusion
b. Apical pulse 110 beats/min such as urine output by the kidneys.
c. Urine output 15 ml for 2 hours The low urine output is an indica-
d. Arterial oxygen saturation 90% tor that renal tissue perfusion is in-
adequate and the patient is in the
progressive stage of shock. The low
BP, increase in pulse, and low-nor-
mal O2 saturation are more typical
of compensated septic shock.
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systolic BP <90 mm Hg.
d. Administer dobutamine (Dobutrex)
to keep systolic BP >90 mm Hg.
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will anticipate the administration of sion. Nitroglycerin
a. nitroglycerine (Tridil). would decrease the preload and
b. drotrecogin alpha (Xigris). further drop cardiac output and BP.
c. norepinephrine (Levophed). Drotrecogin alpha
d. sodium nitroprusside (Nipride). may decrease inappropriate in-
flammation and help prevent sys-
temic inflammatory
response syndrome, but it will not
directly improve blood pressure. Ni-
troprusside is an
arterial vasodilator and would fur-
ther decrease SVR.
DIF: Cognitive Level: Application
REF: 1731 | 1733-1735
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological In-
tegrity
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anticipate further increase heart
a. infusion of 5% human albumin. rate and myocardial oxygen de-
b. administration of furosemide (Lasix) mand. Normal saline infusion
IV. would increase the PAWP
c. titration of an epinephrine (Adrena- further. Hydrocortisone might be
lin) drip. used for septic or anaphylactic
d. administration of hydrocortisone shock.
(SoluCortef). DIF: Cognitive Level: Application
REF: 1735 | 1736 TOP: Nursing
Process:
Planning
MSC: NCLEX: Physiological In-
tegrity
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MSC: NCLEX: Physiological In-
tegrity
84.
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11. Norepinephrine (Levophed) has ANS: A
been prescribed for a patient who was Adequate fluid administration is es-
admitted with sential before administration of va-
dehydration and hypotension. Which sopressors to
patient information indicates that the patients with hypovolemic shock.
nurse should The patient's low central venous
consult with the health care provider pressure indicates a
before administration of the norepi- need for more volume replacement.
nephrine? The other patient data are not con-
a. The patient's central venous pres- traindications to
sure is 3 mm Hg. norepinephrine administration.
b. The patient is receiving low dose DIF: Cognitive Level: Application
dopamine (Intropin). REF: 1733-1735 | 1736
c. The patient is in sinus tachycardia at TOP: Nursing Process: Implemen-
100 to 110 beats/min. tation MSC: NCLEX: Physiological
d. The patient has had no urine output Integrity
since being admitted.
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tic shock has been effective? breathing, the oxygen saturation is
a. Pulse rate the most critical assessment. Im-
b. Orientation provements in the
c. Blood pressure other assessments also will be ex-
d. Oxygen saturation pected with effective treatment of
anaphylactic shock.
DIF: Cognitive Level: Application
REF: 1724-1725 | 1732
TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological In-
tegrity
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glucose at 110 to 150 mg/dL. tion TOP: Nursing Process: Imple-
d. Titrate norepinephrine (Levophed) mentation
to keep mean arterial pressure (MAP) MSC: NCLEX: Physiological In-
at 65 to tegrity
70 mm Hg.
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91. 18. A patient is treated in the emer- ANS: A
gency department (ED) for shock of The initial actions of the nurse
unknown etiology. are focused on the ABCs—airway,
The first action by the nurse should be breathing,
to circulation—and administration of
a. administer oxygen. oxygen should be done first. The
b. attach a cardiac monitor. other actions should
c. obtain the blood pressure. be accomplished as rapidly as pos-
d. check the level of consciousness. sible after oxygen administration.
DIF: Cognitive Level: Application
REF: 1729-1731 | 1732 | 1733 |
1736-1737
OBJ: Special Questions: Prioritiza-
tion TOP: Nursing Process: Imple-
mentation
MSC: NCLEX: Physiological In-
tegrity
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skin; tachycardia; and hypotension. ventilation. Cardiac monitoring, in-
Which of these sertion of IV catheters, and obtain-
prescribed interventions should the ing blood for
nurse implement first? transfusions also should be rapid-
a. Place the patient on continuous car- ly accomplished, but only after ac-
diac monitor. tions to maximize
b. Draw blood to type and crossmatch oxygen delivery have been imple-
for transfusions. mented.
c. Insert two 14-gauge IV catheters in DIF: Cognitive Level: Application
antecubital space. REF: 1732
d. Administer oxygen at 100% per OBJ: Special Questions: Prioritiza-
non-rebreather mask tion TOP: Nursing Process: Imple-
mentation
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sessment
MSC: NCLEX: Physiological In-
tegrity
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units/min.
d. Administer normal saline 1000 mL
over 30 minutes.
e. Titrate oxygen administration to
keep O2 saturation >95%.
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