Chapter 11

Download as pdf or txt
Download as pdf or txt
You are on page 1of 36

Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

Study online at https://quizlet.com/_3mh6qu

1. Fresh frozen plasma (FFP) is adminis- A.clotting factors.


tered to replace: Fresh frozen plasma is adminis-
A.clotting factors. tered to replace all clotting factors
B.erythrocytes. except platelets. Platelets are giv-
C.leukocytes. en rapidly to help control bleeding
D.platelets. caused by low platelet counts.

2. In distributive shock, the major physi- D.vasodilation and relative hypov-


ological problem causing the shock is: olemia.
A.blood loss and actual hypovolemia. Distributive shock presents with
B.decreased cardiac output. widespread vasodilation and de-
C.third spacing of fluids into peri- creased systemic vascular resis-
toneal space. tance that results in a relative hy-
D.vasodilation and relative hypov- povolemia. Blood loss is associ-
olemia. ated with hypovolemic shock. De-
creased cardiac output is a primary
cause of cardiogenic shock. Prima-
ry internal sequestration of fluids
that causes internal fluid loss is as-
sociated with hypovolemic shock.

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.

4. The majority of cases of cardiogenic A.acute myocardial infarction.


shock are caused by: The most common cause of cardio-
A.acute myocardial infarction. genic shock is an extensive left ven-
B.myocardial depression in sepsis. tricular myocardial infarction. My-
C.pulmonary embolism. ocardial depression in sepsis is
D.significant hypovolemia. a secondary problem associated
with the acidosis/anaerobic metab-
1 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
olism of septic shock. Pulmonary
embolism is a cause of obstructive
shock. Fluid loss is the major cause
of hypovolemic shock.

5. When neurogenic shock occurs, inter- D.vasodilation.


ruption in sympathetic nerve impulses In neurogenic shock, there is an in-
causes: terruption of impulse transmission
A.tachycardia. or blockage of sympathetic outflow,
B.hypertension. resulting in vasodilation, inhibition
C.hypoventilation. of baroreceptor response, and im-
D.vasodilation. paired thermoregulation. Interrup-
tion of sympathetic nerve innerva-
tion would result in bradycardia. In-
terruption of sympathetic nerve in-
nervation would result in hypoten-
sion. Hypoventilation is not a phys-
iological mechanism.

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-

2 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

8. The nurse is admitting to the ICU a B.Enteral nutrition initiated within


patient in early sepsis. What is the the first 24 to 48 hours is critical.
nurse's best understanding of the pa- Early enteral nutrition within 24 to
tient's nutritional requirements? 48 hours of admission to an inten-
A.Total parenteral nutrition is pre- sive care unit is supported by ev-
ferred. idence and recommended in pa-
B.Enteral nutrition initiated within the tients with severe sepsis, septic
first 24 to 48 hours is critical. shock, or both. Enteral nutrition is
C.The caloric needs of the patient in the preferred route of administra-
sepsis are significantly lower. tion, as this method assists the in-
D.Early enteral feeding may lead to di- testinal mucosa in maintaining its
arrhea, delaying wound healing. barrier function. The caloric needs
of a patient in sepsis are high
and require increased caloric in-
take. Early enteral feeding decreas-
es diarrhea.

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.

3 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu

10. Which statement correctly reflects A.Lactated Ringer's should not be


crystalloid fluid replacement therapy infused if lactic acidosis is severe.
in shock states? LR solutions contain lactate, which
A.Lactated Ringer's should not be in- the liver converts to bicarbonate.
fused if lactic acidosis is severe. If liver function is normal, this will
B.3 mL of crystalloid is administered counteract lactic acidosis. Howev-
to replace 10 mL of blood loss. er, LR should not be infused if lac-
C.Administration of colloids is pre- tic acidosis is severe. Three mL
ferred over crystalloids. of crystalloid is administered to re-
D.Solutions of 0.45% normal saline are place every 1 mL of blood loss.
used routinely in shock There is no evidence to support
colloid administration being more
beneficial than crystalloid admin-
istration in shock states. Hypoton-
ic solutions such as 0.45% nor-
mal saline are not administered
in shock states as these solu-
tions rapidly leave the intravascular
space, causing interstitial and intra-
cellular edema.

11. The nurse admits a patient to the coro- C.Dobutamine (Dobutrex)


nary care unit in cardiogenic shock. Positive inotropic agents such as
The nurse anticipates administering dobutamine (Dobutrex) are giv-
which medication in an effort to im- en to increase the contractile
prove cardiac output? force of the heart in cardio-
A.Dopamine (Intropin) genic shock. Dopamine (Intropin)
B.Phenylephrine (Neo-Synephrine) is used primarily in low cardiac
C.Dobutamine (Dobutrex) output states to restore vasculare
D.Nitroprusside (Nipride) tone and increase blood pressure.
Neo-Synephrine would be con-
traindicated in cardiogenic shock,
as the vasoconstriction it pro-
duces would exacerbate cardiac
ischemia. Nitroprusside (Nipride)
can improve cardiac performance
in shock states by its reduction of
systemic vascular resistance.

4 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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

13. After receiving handoff report from A.Administer infusion of 500 mL


the night shift, the nurse completes 0.9% normal saline every 4 hours
the morning assessment of a patient as needed if the CVP is < 5 mm Hg.
with severe sepsis. Vital sign assess- D.Administer acetaminophen
ment notes blood pressure 95/60 mm (Tylenol) 650 mg suppository per
Hg, heart rate 110 beats/min, respira- rectum as needed to treat temper-
tions 32 breaths/min, oxygen satura- ature > 101° F
tion (SpO2) 96% on 45% oxygen via Fluid volume resuscitation is a pri-
Venturi mask, temperature 101.5° F, ority in patients with severe sep-
central venous pressure (CVP/RAP) 2 sis to maintain circulating blood vol-
mm Hg, and urine output of 10 mL for ume and end organ perfusion and
the last hour. Given this report, the oxygenation. A 500-mL IV bolus of
nurse obtains orders for treatment that 0.9% normal saline is appropriate
include which of the following? (Select given the patient's CVP of 2 mm
all that apply.) Hg and hourly urine output of 10
A.Administer infusion of 500 mL 0.9% mL/hr. There is no evidence to sup-
normal saline every 4 hours as needed port the need to increase supple-
if the CVP is < 5 mm Hg. mental oxygen. Administration of
B.Increase supplemental oxygen ther- furosemide (Lasix) in the presence
apy to 60% venture of a fluid volume deficit is con-
5 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
mask. traindicated. The fever may need to
C.Administer 40 mg furosemide be treated
(Lasix) intravenously as needed if the
urine output is less than 30 mL/hr.
D.Administer acetaminophen (Tylenol)
650 mg suppository per rectum as
needed to treat temperature > 101° F

14. In the cardiac cycle, the ventricles con- D. systole.


tract during:
A. the refractory period.
B. diastole.
C. repolarization.
D. systole.

15. Arterial baroreceptors are located in C. carotid arteries.


the:
A. renal artery.
B. superior vena cava.
C. carotid arteries.
D. circle of Willis.

16. Which problem is a pathophysiologi- A. Hypoperfusion


cal consequence common to all shock
states?
A. Hypoperfusion
B. Vasoconstriction
C. Pulmonary edema
D. Hypertension

17. A consequence of switching from aer- C. lactic acidosis.


obic to anaerobic cellular metabolism
during shock states is:
A. increased ATP production.
B. cellular dehydration.
C. lactic acidosis.
D. free radical formation.

18. Which of the following conditions is B. Spinal cord injury


not a potential cause of cardiogenic
6 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
shock?
A. Tension pneumothorax
B. Spinal cord injury
C. Tamponade
D. Cardiac arrhythmias

19. Which of the following shock states B. Hypovolemic


manifests with tachycardia, vasocon-
striction, and movement of large vol-
umes of interstitial fluid to the vascular
compartment?
A. Anaphylactic
B. Hypovolemic
C. Neurogenic
D. Septic

20. Which of the following shock states is C. Distributive


(are) characterized by vasodilation of
the systemic arteries?
A. Hypovolemic
B. Cardiogenic
C. Distributive
D. All of the above

21. Which of the following shock states B. Anaphylactic


is (are) characterized by acute, severe
bronchoconstriction?
A. Cardiogenic
B. Anaphylactic
C. Hypovolemic
D. All of the above

22. Causes of hypovolemic shock include C. brainstem injury.


all of the following except:
A. dehydration.
B. blood loss.
C. brainstem injury.
D. diuresis.

23. A. pulmonary edema.


7 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
Clinical manifestations of hypov-
olemic shock include all of the follow-
ing except:
A. pulmonary edema.
B. tachycardia.
C. hypotension.
D. oliguria.

24. During hemorrhagic shock, the clinical C. vasoconstriction of peripheral ar-


manifestations of pale skin and cool terioles.
extremities are most directly caused
by:
A. hypothermia.
B. accumulation of toxic metabolites.
C. vasoconstriction of peripheral arte-
rioles.
D. increased tissue oxygen demand.

25. Neurogenic shock is caused by: D. a lack of sympathetic activity.


A. spinal cord injuries below T6.
B. inhibition of the parasympathetic
nervous system.
C. injury to the cerebral cortex.
D. a lack of sympathetic activity.

26. Which of the following pathophys- C. Decreased peripheral vascular


iological events causes the severe resistance
hypotension observed in neurogenic
shock?
A. Increased capillary permeability
B. Diuresis
C. Decreased peripheral vascular re-
sistance
D. All of the above

27. Anaphylactic shock occurs in re- B. allergic reactions.


sponse to severe:
A. viral infections.
B. allergic reactions.

8 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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

29. Which of the following conditions pre- A. Use of immunosuppressant


sents the most significant risk factor medications
for developing septic shock?
A. Use of immunosuppressant medica-
tions
B. History of severe allergies
C. Diagnosis of chronic congestive
heart failure
D. Genetic predisposition to disorders
of hemostasis

30. What is the primary cause of hypoten- B. Arterial vasodilation


sion in early stages of septic shock?
A. Blood loss
B. Arterial vasodilation
C. Activation of the parasympathetic
nervous system
D. Heart failure

31. Which set of clinical manifestations is A. Tachycardia, hypotension, and


highly characteristic of a septic shock warm skin
state?
A. Tachycardia, hypotension, and
warm skin
B. Confusion, bradycardia, and truncal
9 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
rash
C. Severe respiratory distress, jugular
venous distention, and chest pain
D. Decreased cardiac output, hyper-
tension, and poor skin turgor

32. Which of the following features is high- D. Hypermetabolism


ly characteristic of a septic shock
state?
A. High peripheral vascular resistance
B. Inhibition of the sympathetic ner-
vous system
C. Metabolic alkalosis
D. Hypermetabolism

33. Low levels of which molecule con- C. Activated protein C


tribute to the pathophysiology of sep-
tic shock?
A. Nitric oxide
B. Interleukin 1
C. Activated protein C
D. Epinephrine

34. The most common cause of multiple B. septic shock.


organ dysfunction syndrome (MODS)
is:
A. myocardial infarction.
B. septic shock.
C. chronic pulmonary disease.
D. autoimmune disease.

35. Secondary MODS is defined as the C. an uncontrolled inflammatory re-


progressive dysfunction of two or sponse.
more organ systems resulting from:
A. a drug overdose.
B. severe hemorrhaging.
C. an uncontrolled inflammatory re-
sponse.
D. myocardial depression.

10 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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

37. Which of the following laboratory alter- A. Increased serum creatinine


ations would indicate that a patient is
developing renal failure in MODS?
A. Increased serum creatinine
B. Decreased lactate dehydrogenase
(LDH) levels
C. Decreased blood urea nitrogen
(BUN)
D. Hypokalemia

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

40. Which burn injury is characterized by B. Superficial partial thickness


the immediate appearance of large (second degree)
water-filled blisters and a red wound
bed?
A. First degree
11 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
B. Superficial partial thickness (sec-
ond degree)
C. Deep partial thickness (second de-
gree)
D. Third degree

41. Which burn injury is essentially pain- D. Third degree


less in the wound bed?
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

43. Which of the following physiological B. Hypovolemia


alterations would you expect to see in
the delayed response to a severe burn
injury?
A. Hypoglycemia
B. Hypovolemia
C. Hypometabolism
D. Bleeding from wound beds

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-
12 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

46. Why would a third-degree, circumfer- A. Wound contraction and edema


ential burn of the thigh require prompt can severely impair limb circula-
medical attention? tion.
A. Wound contraction and edema can
severely impair limb circulation.
B. It is difficult to perform skin grafts of
the limbs.
C. Burn shock is inevitable.
D. Third-degree burns are very painful.

47. A patient is treated in the emergency 1.Correct Answer: B


department (ED) for shock of unknown Rationale: The initial actions of the

13 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

48. 2. A diabetic patient who has had vom- Correct Answer: D


iting and diarrhea for the past 3 days Rationale: The patient's history of
is admitted to the hospital with a blood hyperglycemia (and the associated
glucose of 748 mg/ml (41.5 mmol/L) polyuria), vomiting, and diarrhea is
and a urinary output of 120 ml in the consistent with hypovolemia, and
first hour. The vital signs are blood the symptoms are most consis-
pressure (BP) 72/62; pulse 128, irreg- tent with the progressive stage of
ular and thready; respirations 38; and shock. The patient's temperature
temperature 97° F (36.1° C). The pa- of 97° F is inconsistent with sep-
tient is disoriented and lethargic with tic shock. The history is inconsis-
cold, clammy skin and cyanosis in the tent with a diagnosis of cardiogenic
hands and feet. The nurse recognizes shock, and the patient's neurologic
that the patient is experiencing the status is not consistent with refrac-
a. progressive stage of septic shock. tory shock.
b. compensatory stage of diabetic
shock.
c. refractory stage of cardiogenic
shock.
d. progressive stage of hypovolemic
shock.

49. 3. A patient with hypovolemic shock Correct Answer: C


has a urinary output of 15 ml/hr. The Rationale: The release of aldos-
nurse understands that the compen- terone and ADH lead to the de-
satory physiologic mechanism that crease in urine output by increasing
leads to altered urinary output is the reabsorption of sodium and wa-
a. activation of the sympathetic ner- ter in the renal tubules. SNS stim-
vous system (SNS), causing vasodila- ulation leads to renal artery vaso-
tion of the renal arteries. constriction. -Receptor stimulation
b. stimulation of cardiac -adrenergic does increase cardiac output, but
receptors, leading to increased car- this would improve urine output.

14 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

50. 4. While caring for a seriously ill pa- Correct Answer: B


tient, the nurse determines that the Rationale: Restlessness and ap-
patient may be in the compensatory prehension are typical during the
stage of shock on finding compensatory stage of shock.
a. cold, mottled extremities. Cold, mottled extremities, cool and
b. restlessness and apprehension. clammy skin, and a systolic BP less
c. a heart rate of 120 and cool, clammy than 90 are associated with the pro-
skin. gressive and refractory stages.
d. systolic BP less than 90 mm Hg.

51. 5. When assessing the hemodynamic Correct Answer: A


information for a newly admitted pa- Rationale: A high cardiac output
tient in shock of unknown etiology, the and low CVP suggest septic shock,
nurse will anticipate administration of and massive fluid replacement is
large volumes of crystalloids when the indicated. Increased PAWP indi-
a. cardiac output is increased and the cates that the patient has excessive
central venous pressure (CVP) is low. fluid volume (and suggests cardio-
b. pulmonary artery wedge pressure genic shock), and diuresis is indi-
(PAWP) is increased, and the urine out- cated. Bradycardia and a low sys-
put is low. temic vascular resistance (SVR)
c. heart rate is decreased, and the sys- suggest neurogenic shock, and flu-
temic vascular resistance is low. ids should be infused cautiously.
d. cardiac output is decreased and the
PAWP is high.

52. 6. A patient who has been involved in Correct Answer: B


a motor-vehicle crash is admitted to Rationale: The first priority in the
the ED with cool, clammy skin, tachy- initial management of shock is
cardia, and hypotension. All of these maintenance of the airway and ven-
orders are written. Which one will the tilation. Cardiac monitoring, inser-
nurse act on first? tion of IV catheters, and obtaining

15 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

53. 7. A patient with massive trauma and Correct Answer: C


possible spinal cord injury is admit- Rationale: The normal sympathetic
ted to the ED. The nurse suspects that response to shock/hypotension is
the patient may be experiencing neu- an increase in heart rate. The pres-
rogenic shock in addition to hypov- ence of bradycardia suggests un-
olemic shock, based on the finding of opposed parasympathetic function,
a. cool, clammy skin. as occurs in neurogenic shock. The
b. shortness of breath. other symptoms are consistent with
c. heart rate of 48 beats/min hypovolemic shock.
d. BP of 82/40 mm Hg.

54. 8. The nurse caring for a patient in Correct Answer: B


shock notifies the health care provider Rationale: The patient's low pH in
of the patient's deteriorating status spite of a respiratory alkalosis in-
when the patient's ABG results include dicates that the patient has se-
a. pH 7.48, PaCO2 33 mm Hg. vere metabolic acidosis and is ex-
b. pH 7.33, PaCO2 30 mm Hg. periencing the progressive stage
c. pH 7.41, PaCO2 50 mm Hg. of shock; rapid changes in therapy
d. pH 7.38, PaCO2 45 mm Hg. are needed. The values in the an-
swer beginning "pH 7.48" suggest
a mild respiratory alkalosis (con-
sistent with compensated shock).
The values in the answer begin-
ning "pH 7.41" suggest compensat-
ed respiratory acidosis. The values
in the answer beginning "pH 7.38"
are normal.

55. 9. The patient with neurogenic Correct Answer: C


shock is receiving a phenylephrine Rationale: The coldness and pal-
(Neo-Synephrine) infusion through a lor at the infusion site suggest ex-

16 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

57. 11. A patient who is receiving Correct Answer: B


chemotherapy is admitted to the hos- Rationale: The patient who has re-
pital with acute dehydration caused ceived chemotherapy is immune
by nausea and vomiting. Which action compromised, and placing the pa-
will the nurse include in the plan of tient in a private room will decrease
care to best prevent the development the exposure to other patients and
of shock, systemic inflammatory re- reduce infection/sepsis risk. Ad-
sponse syndrome (SIRS), and multior- ministration of medications through
gan dysfunction syndrome (MODS)? the central line increases the risk

17 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

58. 12. All of these collaborative interven- Correct Answer: A


tions are ordered by the health care Rationale: Epinephrine rapidly
provider for a patient stung by a bee causes peripheral vasoconstric-
who develops severe respiratory dis- tion, dilates the bronchi, and blocks
tress and faintness. Which one will the the effects of histamine and revers-
nurse administer first? es the vasodilation, bronchocon-
a. Epinephrine (Adrenalin) striction, and histamine release
b. Normal saline infusion that cause the symptoms of ana-
c. Dexamethasone (Decadron) phylaxis. The other interventions
d. Diphenhydramine (Benadryl) are also appropriate but would not
be the first ones administered.

59. 13. A patient with a myocardial infarc- Correct Answer: A


tion (MI) and cardiogenic shock has Rationale: The PAWP indicates that
the following vital signs: BP 86/50, the patient's preload is elevated
pulse 126, respirations 30. Hemody- and furosemide is indicated to re-
namic monitoring reveals an elevated duce the preload and improve car-
PAWP and decreased cardiac output. diac output. Epinephrine would fur-
The nurse will anticipate ther increase myocardial oxygen
a. administration of furosemide (Lasix) demand and might extend the MI.
IV. The PAWP is already elevated, so
b. titration of an epinephrine (Adrena- normal saline boluses would be
lin) drip. contraindicated. There is no indica-
c. administration of a normal saline bo- tion that the patient requires endo-
lus. tracheal intubation.
d. assisting with endotracheal intuba-
tion.

18 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

62. 16. The nurse is caring for a patient Correct Answer: D


admitted with a urinary tract infec- Rationale: Hypothermia is an indi-

19 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

63. 17. Norepinephrine (Levophed) has Correct Answer: B


been ordered for the patient in hypo- Rationale: If vasoconstrictors are
volemic shock. Before administering given in a hypovolemic patient, the
the drug, the nurse ensures that the peripheral vasoconstriction will fur-
a. patient's heart rate is less than 100. ther decrease tissue perfusion. A
b. patient has received adequate fluid patient with hypovolemia is likely
replacement. to have a heart rate greater than
c. patient's urine output is within nor- 100 and a low urine output, so
mal range. these values are not contraindica-
d. patient is not receiving other sympa- tions to vasoconstrictor therapy. Pa-
thomimetic drugs. tients may receive other sympath-
omimetic drugs concurrently with
Levophed.

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.

20 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu

65. 19. While assessing a patient in shock Correct Answer: A


who has an arterial line in place, the Rationale: A postural drop in BP is
nurse notes a drop in the systolic BP an indication of volume depletion
from 92 mm Hg to 76 mm Hg when the and suggests the need for addition-
head of the patient's bed is elevated al fluid infusions. There are no data
to 75 degrees. This finding indicates a to suggest that antibiotics, sympa-
need for thomimetics, or additional oxygen
a. additional fluid replacement. are needed.
b. antibiotic administration.
c. infusion of a sympathomimetic
drug.
d. administration of increased oxygen.

66. 20. The best nursing intervention for Correct Answer: D


a patient in shock who has a nursing Rationale: The patient who is fear-
diagnosis of fear related to perceived ful should feel that the nurse is im-
threat of death is to mediately available if needed. Pas-
a. arrange for the hospital pastoral toral care staff should be asked to
care staff to visit the patient. visit only after checking with the
b. ask the health care provider to pre- patient to determine whether this
scribe a sedative drug for the patient. is desired. Providing time for fami-
c. leave the patient alone with family ly to spend with the patient is ap-
members whenever possible. propriate, but patients and family
d. place the patient's call bell where it should not feel that the nurse is un-
can be easily reached. available. Sedative administration
is helpful but does not as directly
address the patient's anxiety about
dying.

67. 21. A patient outcome that is appropri- Correct Answer: A


ate for the patient in shock who has Rationale: A urine output of 0.5
a nursing diagnosis of decreased car- ml/kg/hr indicates adequate renal
diac output related to relative hypov- perfusion, which is a good indica-
olemia is tor of cardiac output. The patient
a. urine output of 0.5 ml/kg/hr. may continue to have peripheral
b. decreased peripheral edema. edema because fluid infusions may
c. decreased CVP. be needed despite third-spacing of
d. oxygen saturation 90% or more. fluids in relative hypovolemia. De-
creased central venous pressure
21 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
(CVP) for a patient with relative hy-
povolemia indicates that additional
fluid infusion is necessary. An oxy-
gen saturation of 90% will not nec-
essarily indicate that cardiac output
has improved.

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.

69. 23. A patient in compensated septic Correct Answer: A


shock has hemodynamic monitoring Rationale: In the early stages of
with a pulmonary artery catheter and septic shock, the cardiac output
an arterial catheter. Which information is high. The other hemodynamic
obtained by the nurse indicates that changes would indicate that the pa-
the patient is still in the compensatory tient had developed progressive or
stage of shock? refractory septic shock.
a. The cardiac output is elevated.
b. The central venous pressure (CVP)
is increased.
c. The systemic vascular resistance
(SVR) is high.
d. The PAWP is high.

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-

22 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

71. 25. To monitor a patient with severe Correct Answer: B


acute pancreatitis for the early organ Rationale: The respiratory system
damage associated with MODS, the is usually the system to show the
most important assessments for the signs of MODS because of the di-
nurse to make are rect effect of inflammatory media-
a. stool guaiac and bowel sounds. tors on the pulmonary system. The
b. lung sounds and oxygenation sta- other assessment data are also im-
tus. portant to collect, but they will not
c. serum creatinine and urinary output. indicate the development of MODS
d. serum bilirubin levels and skin col- as early.
or.

72. 26. An assessment finding indicating Correct Answer: B


to the nurse that a 70-kg patient in Rationale: A fixed urine specif-
septic shock is progressing to MODS ic gravity points to an inability of
includes the kidney to concentrate urine
a. respiratory rate of 10 breaths/min. caused by acute tubular necrosis.
b. fixed urine specific gravity at 1.010. With MODS, the patient's respirato-
c. MAP of 55 mm Hg. ry rate would initially increase. The
d. 360-ml urine output in 8 hours. MAP of 55 shows continued shock,
but not necessarily progression to
MODS. A 360-ml urine output over
8 hours indicates adequate renal
perfusion.

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-

23 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

74. 1. A patient with septic shock has a ANS: A


urine output of 20 mL/hr for the past 3 Furosemide will lower the filling
hours. The pulse pressures and renal perfusion fur-
rate is 120 and the central venous ther for the patient
pressure and pulmonary artery wedge with septic shock. The other orders
pressure are low. are appropriate.
Which of these orders by the health DIF: Cognitive Level: Application
care provider will the nurse question? REF: 1724-1726 | 1731 | 1733
a. Give furosemide (Lasix) 40 mg IV. TOP: Nursing Process: Implemen-
b. Increase normal saline infusion to tation MSC: NCLEX: Physiological
150 mL/hr. Integrity
c. Administer hydrocortisone (Solu-
Cortef) 100 mg IV.
d. Prepare to give drotrecogin alpha
(Xigris) 24 mcg/kg/hr.

75. 2. A patient with shock of unknown eti- ANS: A


ology whose hemodynamic monitor- The patient's elevated pulmonary
ing indicates BP artery wedge pressure indicates
92/54, pulse 64, and an elevated pul- volume excess. A
monary artery wedge pressure has the normal saline infusion at 250 mL/hr
following will exacerbate this. The other ac-
collaborative interventions pre- tions are
scribed. Which intervention will the appropriate for the patient.
nurse question? DIF: Cognitive Level: Application
a. Infuse normal saline at 250 mL/hr. REF: 1719 | 1721-1722 | 1735
b. Keep head of bed elevated to 30 de- TOP: Nursing Process: Planning
grees. MSC: NCLEX: Physiological In-
c. Give nitroprusside (Nipride) unless tegrity

24 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
systolic BP <90 mm Hg.
d. Administer dobutamine (Dobutrex)
to keep systolic BP >90 mm Hg.

76. 3. A patient with massive trauma and ANS: C


possible spinal cord injury is admitted Neurogenic shock is characterized
to the by hypotension and bradycardia.
emergency department (ED). Which The other findings
finding by the nurse will help confirm would be more consistent with oth-
a diagnosis of er types of shock.
neurogenic shock? DIF: Cognitive Level: Comprehen-
a. Cool, clammy skin sion REF: 1721-1722 | 1723
b. Inspiratory crackles TOP: Nursing Process: Assess-
c. Apical heart rate 48 beats/min ment MSC: NCLEX: Physiological
d. Temperature 101.2° F (38.4° C) Integrity

77. 4. A patient with cardiogenic shock is ANS: D


cool and clammy and hemodynamic Nitroprusside is an arterial va-
monitoring sodilator and will decrease the SVR
indicates a high systemic vascular re- and afterload, which
sistance (SVR). Which action will the will improve cardiac output.
nurse Changes in the D5W and nitroglyc-
anticipate taking? erin infusions will not
a. Increase the rate for the prescribed directly increase SVR. Increasing
dopamine (Intropin) infusion. the dopamine will tend to increase
b. Decrease the rate for the prescribed SVR.
nitroglycerin (Tridil) infusion. DIF: Cognitive Level: Application
c. Decrease the rate for the prescribed REF: 1733-1734 TOP: Nursing
5% dextrose in water (D5W) infusion. Process:
d. Increase the rate for the prescribed Planning
sodium nitroprusside (Nipride) infu- MSC: NCLEX: Physiological In-
sion. tegrity

78. 5. After receiving 1000 mL of normal ANS: C


saline, the central venous pressure for When fluid resuscitation is unsuc-
a patient who cessful, vasopressor drugs are ad-
has septic shock is 10 mm Hg, but the ministered to increase
blood pressure is still 82/40 mm Hg. the systemic vascular resistance
The nurse (SVR) and improve tissue perfu-

25 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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

79. 6. To evaluate the effectiveness of the ANS: C


omeprazole (Prilosec) being adminis- Proton pump inhibitors are given to
tered to a patient decrease the risk for stress ulcers
with systemic inflammatory response in critically ill
syndrome (SIRS), which assessment patients. The other assessments
will the nurse also will be done, but these will not
make? help in determining
a. Auscultate bowel sounds. the effectiveness of the omeprazole
b. Ask the patient about nausea. administration.
c. Monitor stools for occult blood. DIF: Cognitive Level: Application
d. Check for abdominal distention. REF: 1735-1737 | 1742-1743
TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological In-
tegrity

80. 7. A patient with cardiogenic shock ANS: B


has the following vital signs: BP 86/50, The PAWP indicates that the pa-
pulse 126, tient's preload is elevated and
respirations 30. The PAWP is increased furosemide is indicated to
and cardiac output is low. The nurse reduce the preload and improve
will cardiac output. Epinephrine would

26 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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

81. 8. The emergency department (ED) re- ANS: C


ceives notification that a patient who A patient with multiple trauma may
has just been in require fluid resuscitation to pre-
an automobile accident is being trans- vent or treat
ported to your facility with anticipated hypovolemic shock, so the nurse
arrival in 1 will anticipate the need for 2 large
minute. In preparation for the patient's bore IV lines to
arrival, the nurse will obtain administer normal saline. Lactated
a. 500 mL of 5% albumin. Ringer's solution should be used
b. lactated Ringer's solution. cautiously and will
c. two 14-gauge IV catheters. not be ordered until the patient has
d. dopamine (Intropin) infusion. 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.
DIF: Cognitive Level: Application
REF: 1731 | 1732 | 1733
TOP: Nursing Process: Planning

27 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
MSC: NCLEX: Physiological In-
tegrity

82. 9. Which of these findings is the best ANS: B


indicator that the fluid resuscitation Assessment of end organ perfu-
for a patient with sion, such as an adequate urine
hypovolemic shock has been success- output, is the best indicator
ful? that fluid resuscitation has been
a. Hemoglobin is within normal limits. successful. The hemoglobin level,
b. Urine output is 60 mL over the last PAWP, and MAP are
hour. useful in determining the effects of
c. Pulmonary artery wedge pressure fluid administration, but they are not
(PAWP) is normal. as useful as data
d. Mean arterial pressure (MAP) is 65 indicating good organ perfusion.
mm Hg. DIF: Cognitive Level: Application
REF: 1733-1735 TOP: Nursing
Process:
Evaluation
MSC: NCLEX: Physiological In-
tegrity

83. 10. Which intervention will the nurse ANS: C


include in the plan of care for a patient Since pulmonary congestion and
who has dyspnea are characteristics of car-
cardiogenic shock? diogenic shock, the
a. Avoid elevating head of bed. nurse should assess the breath
b. Check temperature every 2 hours. sounds frequently. The head of the
c. Monitor breath sounds frequently. bed is usually elevated
d. Assess skin for flushing and itching. to decrease dyspnea. Elevated
temperature and flushing or itching
of the skin are not
typical of cardiogenic shock.
DIF: Cognitive Level: Application
REF: 1721
TOP: Nursing Process: Implemen-
tation MSC: NCLEX: Physiological
Integrity

84.

28 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

85. 12. When the nurse is assessing a pa- ANS: B


tient who is receiving a nitroprusside Warm, pink, and dry skin indicates
(Nipride) infusion that perfusion to tissues is im-
to treat cardiogenic shock, which find- proved. Since
ing indicates that the medication is ef- nitroprusside is a vasodilator, the
fective? blood pressure may be low even if
a. No heart murmur is audible. the medication is
b. Skin is warm, pink, and dry. effective. Absence of a heart mur-
c. Troponin level is decreased. mur and a decrease in troponin lev-
d. Blood pressure is 90/40 mm Hg. el are not indicators
of improvement in shock.
DIF: Cognitive Level: Application
REF: 1721 | 1723 | 1733-1735
TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological In-
tegrity

86. 13. Which assessment is most impor- ANS: D


tant for the nurse to make in order to Because the airway edema that is
evaluate whether associated with anaphylaxis can af-
treatment of a patient with anaphylac- fect airway and

29 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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

87. 14. Which information obtained by the ANS: A


nurse when caring for a patient who The elevated serum creatinine level
has cardiogenic indicates that the patient has renal
shock indicates that the patient may failure as well as
be developing multiple organ dysfunc- heart failure. The crackles, chest
tion syndrome pressure, and cool extremities are
(MODS)? all consistent with the
a. The patient's serum creatinine level patient's diagnosis of cardiogenic
is elevated. shock.
b. The patient complains of intermit- DIF: Cognitive Level: Application
tent chest pressure. REF: 1740-1741
c. The patient has crackles throughout TOP: Nursing Process: Assess-
both lung fields. ment MSC: NCLEX: Physiological
d. The patient's extremities are cool Integrity
and pulses are weak.

88. 15. A patient with septic shock has a ANS: A


BP of 70/46 mm Hg, pulse 136, respira- Because of the low systemic vas-
tions 32, cular resistance (SVR) associated
temperature 104° F, and blood glucose with septic shock, fluid
246 mg/dL. Which of these prescribed resuscitation is the initial therapy.
interventions will the nurse implement The other actions also are appro-
first? priate and should be
a. Give normal saline IV at 500 mL/hr. initiated quickly as well.
b. Infuse drotrecogin- (Xigris) 24 DIF: Cognitive Level: Application
mcg/kg. REF: 1735-1737
c. Start insulin drip to maintain blood OBJ: Special Questions: Prioritiza-

30 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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.

89. 16. When the charge nurse is evaluat- ANS: C


ing the skills of a new RN, which action Patients with neurogenic shock
by the new RN may have poikilothermia. The room
indicates a need for more education in temperature should
the care of patients with shock? be kept warm to avoid hypothermia.
a. Placing the pulse oximeter on the The other actions by the new RN
ear for a patient with septic shock are appropriate.
b. Keeping the head of the bed flat for DIF: Cognitive Level: Application
a patient with hypovolemic shock REF: 1721-1722 | 1724
c. Decreasing the room temperature OBJ: Special Questions: Delega-
to 68° F for a patient with neurogenic tion TOP: Nursing Process: Evalu-
shock ation
d. Increasing the nitroprusside MSC: NCLEX: Safe and Effective
(Nipride) infusion rate for a patient Care Environment
with a high SVR

90. 17. When caring for a patient who has ANS: B


septic shock, which assessment find- Since patients in the early stage of
ing is most septic shock have warm and dry
important for the nurse to report to the skin, the patient's
health care provider? cool and clammy skin indicates that
a. BP 92/56 mm Hg shock is progressing. The other in-
b. Skin cool and clammy formation also will
c. Apical pulse 118 beats/min be reported, but does not indicate
d. Arterial oxygen saturation 91% deterioration of the patient's status.
DIF: Cognitive Level: Application
REF: 1723
OBJ: Special Questions: Prioriti-
zation TOP: Nursing Process: As-
sessment
MSC: NCLEX: Physiological In-
tegrity

31 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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

92. 19. During change-of-shift report, the ANS: D


nurse learns that a patient has been The changes in mental status are
admitted with indicative that the patient is in the
dehydration and hypotension after progressive stage of
having vomiting and diarrhea for 3 shock and that rapid intervention is
days. Which needed to prevent further deterio-
finding is most important for the nurse ration. The other
to report to the health care provider? information is consistent with com-
a. Decreased bowel sounds pensatory shock.
b. Apical pulse 110 beats/min DIF: Cognitive Level: Application
c. Pale, cool, and dry extremities REF: 1728-1729
d. New onset of confusion and agita- OBJ: Special Questions: Prioriti-
tion zation TOP: Nursing Process: As-
sessment
MSC: NCLEX: Physiological In-
tegrity

93. 20. A patient who has been involved ANS: D


in a motor vehicle crash is admitted to The first priority in the initial man-
the emergency agement of shock is maintenance
department (ED) with cool, clammy of the airway and

32 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
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

94. 21. The patient with neurogenic ANS: A


shock is receiving a phenylephrine The coldness and pallor at the in-
(Neo-Synephrine) fusion site suggest extravasation of
infusion through a left forearm IV. the phenylephrine.
Which assessment information ob- The nurse should discontinue the
tained by the nurse IV and, if possible, infuse the med-
indicates a need for immediate action? ication into a central
a. The patient's IV infusion site is cool line. An apical pulse of 58 is typical
and pale. for neurogenic shock but does not
b. The patient has warm, dry skin on indicate an
the extremities. immediate need for nursing inter-
c. The patient has an apical pulse rate vention. A 28 mL urinary output
of 58 beats/min. over 1 hour would
d. The patient's urine output has been require the nurse to monitor the
28 mL over the last hour. output over the next hour, but an
immediate change in
therapy is not indicated. Warm, dry
skin is consistent with early neuro-
genic shock, but it
does not indicate a need for a
change in therapy or immediate ac-
tion.
DIF: Cognitive Level: Application
REF: 1733-1734
OBJ: Special Questions: Prioriti-
33 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
zation TOP: Nursing Process: As-
sessment
MSC: NCLEX: Physiological In-
tegrity

95. 22. The following therapies are pre- ANS: B


scribed by the health care provider for Epinephrine rapidly causes periph-
a patient who has eral vasoconstriction, dilates the
respiratory distress and syncope after bronchi, and blocks
a bee sting. Which will the nurse ad- the effects of histamine and revers-
minister first? es the vasodilation, bronchocon-
a. normal saline infusion striction, and histamine
b. epinephrine (Adrenalin) release that cause the symptoms
c. dexamethasone (Decadron) of anaphylaxis. The other interven-
d. diphenhydramine (Benadryl) tions also are
appropriate but would not be the
first ones administered.
DIF: Cognitive Level: Application
REF: 1736-1737
OBJ: Special Questions: Prioritiza-
tion TOP: Nursing Process: Imple-
mentation
MSC: NCLEX: Physiological In-
tegrity

96. 23. Which information about a pa- ANS: B


tient who is receiving vasopressin Because vasopressin is a potent
(Pitressin) to treat septic vasoconstrictor, it may decrease
shock is most important for the nurse coronary artery
to communicate to the heath care perfusion. The other information is
provider? consistent with the patient's diag-
a. The patient's heart rate is 108 nosis and should be
beats/min. reported to the health care provider
b. The patient is complaining of chest but does not indicate a need for a
pain. change in therapy.
c. The patient's peripheral pulses are DIF: Cognitive Level: Application
weak. REF: 1735-1736
d. The patient's urine output is 15 OBJ: Special Questions: Prioriti-
mL/hr. zation TOP: Nursing Process: As-

34 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
sessment
MSC: NCLEX: Physiological In-
tegrity

97. 1. A patient with neurogenic shock has ANS: A, B, C, E


just arrived in the emergency depart- All of the actions are appropriate
ment after a except to give large volumes of lac-
diving accident. He has a cervical col- tated Ringer's
lar in place. Which of the following ac- solution. The patient with neuro-
tions should genic shock usually has a normal
the nurse take (select all that apply)? blood volume, and it is
a. Prepare to administer atropine IV. important not to volume overload
b. Obtain baseline body temperature. the patient. In addition, lactated
c. Prepare for intubation and mechan- Ringer's solution is
ical ventilation. used cautiously in all shock situa-
d. Administer large volumes of lactat- tions because the failing liver can-
ed Ringer's solution. not convert lactate to
e. Administer high-flow oxygen (100%) bicarbonate.
by non-rebreather mask. DIF: Cognitive Level: Application
REF: 1736-1737
OBJ: Special Questions: Alternate
Item Format
TOP: Nursing Process: Implemen-
tation MSC: NCLEX: Physiological
Integrity

98. 1. The health care provider prescribes ANS:


these actions for a patient who has E, D, C, A, B
possible septic The initial action for this hypoten-
shock with a BP of 70/42 mm Hg and sive and hypoxemic patient should
oxygen saturation of 90%. In which or- be to improve the
der will the oxygen saturation, followed by infu-
nurse implement the actions? Put a sion of IV fluids and vasopressors
comma and space between each an- to improve
swer choice (a, b, perfusion. Cultures should be ob-
c, d, etc.) ____________________ tained before administration of an-
a. Obtain blood and urine cultures. tibiotics.
b. Give vancomycin (Vancocin) 1 g IV.
c. Infuse vasopressin (Pitressin) 0.01

35 / 36
Chapter 11 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Study online at https://quizlet.com/_3mh6qu
units/min.
d. Administer normal saline 1000 mL
over 30 minutes.
e. Titrate oxygen administration to
keep O2 saturation >95%.

36 / 36

You might also like