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RN Critical Care Nursing 2023-2024 EXAM PREPARATION |VERIFIED |APPROVED|GRADED A+
Typology: Exams
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● Decreased tissue perfusion ● Cells lack oxygen & nutrients and they will eventually die, organs will fail ● Shock is rapidly progressive, life threatening (triggers flight or fight syndrome) ● Early detection of shock with rapid response is necessary to improve patient outcome ● If patient is in shock assess them more often because they have reduced compensatory mechanisms and rapidly progressing through the stages of shock ● Catecholamines might not increase vasoconstriction in elderly as in younger adults due to decreased baroreceptor response. ● Elderly patient requires more frequent monitoring because compensatory mechanism
TB QUESTION
A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient’s health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion. Ans: B Feedback: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock
S/S of neurogenic shock :
● Decreased B/P (hypotension), tachycardia, decreased urinary output, altered loss of
concentration ● Warm, dry skin due to loss of sympathetic muscle ● Abnormal hemodynamic measurements, ABG's
● The person will not have sympathetic response to the point of injury ● Blood pressure cannot be maintained; they will have massive vasodilation & loss of sympathetic tone ● Can be as a result of head trauma, spinal chord injury, epidural anesthesia, or a car accident where they lose a lot of blood ● Exam question will say“Spinal chord injury”= possibility of neurogenic shock
A patient with a T2 spinal cord injury is exhibiting manifestations of neurogenic shock. The nurse would be correct in monitoring for which of the following? A) Increased cardiac markers B) Hypotension C) Tachycardia D) Excessive sweating ANS: B
TB QUESTION
The ICU nurse is caring for a patient in neurogenic shock following an overdose of antianxiety medication. When assessing this patient, the nurse should recognize what characteristic of neurogenic shock? A) Hypertension B) Cool, moist skin C) Bradycardia D) Signs of sympathetic stimulation
Ans: C Feedback: In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.
A nurse in the ICU receives a report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing? A. Anaphylactic shock B. Neurogenic shock
C. Septic shock D. Hypovolemic shock
Feedback: Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.
● They will need increased calories because they are in a hypercaloric state- burning more calories due to the shock ● The release of catecholamines creates an increase in metabolic rate and metabolic requirements ● There is a rapid depletion of glucose stores early in shock (pt may require more than 3,000 cals per day) ● Requirements are met by breaking down lean mass. In this catabolic process skeletal muscle mass is broken down even when the pt has large stores of adipose tissue. Loss of skeletal muscle further prolongs recovery time. Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the GI tract. Therefore, antacids, H2 blockers and PPIs may be prescribed (rxed) to prevent ulcer formation ● Enteral feedings are preferred to parenteral feedings to reduce the risk of infection ● Hypermetabolic state
In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the body’s needs? A) It slows the proliferation of bacteria and viruses during shock. B) It decreases the energy expended through the functioning of the GI system. C) It assists in expanding the intravascular volume of the body. D) It promotes GI function through direct exposure to nutrients.
Ans: D Feedback: Parenteral or enteral nutritional support should be initiated as soon as possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feeding. Enteral feeding does not decrease the proliferation of microorganisms or the amount of energy
expended through the functioning of the GI system and it does not assist in expanding the intravascular volume of the body.
The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patient’s nutritional needs. What physiologic process contributes to these increased nutritional needs? A) The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate (ATP) B) The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements. D) The increase in GI peristalsis during shock and the resulting diarrhea.
Ans: C Feedback: Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity but are instead related to increased sympathetic activity. GI function does not increase during shock.
○ Urinary output usually decreases to less than 0.5 mL/kg per hour (or less than 30 mL per hour) ○ Hypernatremia stimulates the release of ADH by the pituitary gland, ADH then causes the kidneys to retain water in an effort to raise BP and blood volume. ■ Leads to decreased UOP
The acute care nurse is providing care for an adult patient who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock? A) Increased hunger B) Decreased thirst C) Decreased urinary output
D) Increased capillary perfusion
Ans: C Feedback: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs
Give in a short period of time (5 min or less), has to be administered through a central line to
prevent necrosis
○ Dopamine is a vasopressor that is used to strengthen cardiac contraction and increase cardiac output ○ Doses are carefully titrated because a dose too high (<8g/dL) can have the opposite effect and cause vasoconstriction thus increasing afterload and increases cardiac workload ■ Can compromise perfusion to the skin kidneys, lungs and GI tract if afterload increases ○ Nursing considerations: ■ Administer by continuous IV infusion with CONSTANT HEMODYNAMIC monitoring ■ Monitor UOP ■ Administer through a central line to prevent extraversion. Rapid onset occurs in 5 mins and short duration occurs in 10 mins
A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse’s care planning during the administration of a vasoactive drug? A) The drug should be discontinued immediately after blood pressure increases. B) The drug dose should be tapered down once vital signs improve. C) The patient should have arterial blood gasses drawn every 10 minutes during treatment. D) The infusion rate should be titrated according to the patient’s subjective sensation of adequate perfusion.
Ans: B Feedback: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the
shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but every10- minute draws are not the norm
TB QUESTION
The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? A) Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient education C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema D) Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions Ans: A Feedback: When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing.
● All types of shock progress through the same stages ● Initial stage: no visible changes in patient parameters; only changes on the cellular level ● Compensatory (non progressive): measures to increase cardiac output to restore tissue perfusion and oxygenation ● Progressive: compensatory mechanisms begin to fail ● Refractory: irreversible shock and total body failure ● Shock stages progress along a continuum and can be identified as early or late depending on the sign and symptoms and overall severity of organ dysfunction ● Stage 1: Compensatory ○ Normal Blood pressure ○ Inadequate organ perfusion ○ Metabolic ACIDOSIS [from build up of lactic acid from anaerobic metabolism] ○ Rapid respiratory rate [to get rid of the CO2] → may then raise the blood pH causing a compensatory respiratory alkalosis ○ Pt may have a change in affect, confusion or anxiety ● Stage 2: Progressive ○ HYPOTENSIVE [ Systolic <90 or Diastolic <40 from baseline] ○ Rapid shallow respirations [mechanical ventilation is likely warranted] ○ Crackles
○ Declining mental status; agitation, confusion or delirium ○ HF [from myocardial depression] ○ Dysrhythmias and Ischemia [body cannot meet o2 demand] ○ Rapid HR [sometimes <150BPM] ○ AKI(Acute Kidney Injury) may be likely and UOP decreases ○ Liver enzymes and bilirubin are elevated ○ Decreased ability to metabolize medications and waste products ○ Stress ulcers in the stomach, may lead to GI bleeding ● Stage 3: irreversible ○ Organ damage is so severe the pt does not respond and cannot survive ○ Low bp ○ Impaired renal and liver function ○ Acute metabolic acidosis ● The earlier the interventions are initiated along the continuum the better the chance of survival
The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply. A) Drop in systolic blood pressure of 40 mm Hg from baselines B) Hypotension that responds to bolus fluid resuscitation C) Exaggerated response to vasoactive medications D) Serum lactate >4 mmol/L E) Mean arterial pressure (MAP) of ˂65 mm Hg Ans: A, D, E Feedback: Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or mean arterial pressure (MAP) <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted
TB QUESTION
The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse’s assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse’s analysis of these data should lead to what preliminary conclusion? A) The patient is in the compensatory stage of shock. B) The patient is in the progressive stage of shock. C) The patient will stabilize and be released by tomorrow. D) The patient is in the irreversible stage of shock.
Feedback: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the patient’s chance of survival is low, and he will certainly not be released within 24 hours. If the patient were in the irreversible stage of shock, his blood pressure would be very low, and his organs would be failing.
● Cardiogenic shock is failure of the heart to pump effectively due to cardiac factor ● Opioid analgesic will help reduce pain & vasodilation of coronary arteries- Morphine sulfate. Sodium Nitroprusside (causes vasodilation) will also be used to treat neurogenic shock ● Monitor respirations of clients who are non ventilated, monitor blood pressure, heart rate, and SaO2. ● Educate patient about ways to reduce risk of myocardial infarction, such as diet, stress reduction, and smoke cessation. ● Older adult patients are at risk for MI and cardiomyopathy ● Use cautiously due to risk of increased vasodilation and hypotension ● Have naloxone and resuscitation equipment available for severe respiratory depression in a patient who is non ventilated
The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient? A) It promotes coping and slows catecholamine release. B) It stimulates the patient so he or she is more alert. C) It decreases gastric secretions. D) It dilates the blood vessels.
Ans: D Feedback: For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patient’s anxiety. Morphine would not be ordered to promote coping or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions.
● Elevate the heart rate
● The body wants to increase blood volume ● Cardiac output is volume ejected by the heart
TB QUESTION
The nurse is providing care for a patient who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states? A) Third spacing of fluid B) Dysrhythmias C) Tachycardia D) Gastric hypermotility
Ans: C Feedback: Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms
○ Provide o2 (possibly by mechanical ventilation) ○ Fluid replacement (isotonic crystalloid, colloid or blood products) ○ Give vasoactive meds as rxed (prescribed) to restore vasoactive tone and improve cardiac function ○ Nutritional support to provide for the massive caloric requirement ○ Check vital signs ○ Cardiac rhythm with continuous cardiac monitoring ○ Check the skin color, temperature, moisture, capillary refill, turgor (Decreased) ○ Place the client on high flow oxygen, 100% non rebreather mask (if they have COPD ○ Maintain patent IV access ○ For hypotension, place client with both legs elevated
A critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock? A) Aggressive hypoglycemic control B) Administration of hypertonic IV fluids C) Early provision of nutritional support D) Aggressive antibiotic therapy.
Ans: C Feedback: Nutritional support is necessary for all patients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many patients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in patients with septic shock.
TB QUESTION
The nurse in a rural nursing outpost has just been notified that she will be receiving a patient in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. You know that the best choice for fluid replacement for this patient is what? A) 5% albumin because it is inexpensive and is always readily available B) Dextran because it increases intravascular volume and counteracts coagulopathy C) Whatever fluid is most readily available in the clinic, due to the nature of the emergency D) Lactated Ringer’s solution because it increases volume, buffers acidosis, and is the best choice for patients with liver failure
Ans: C Feedback: The best fluid to treat shock remains controversial. In emergencies, the “best” fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids can be administered to restore intravascular volume.
Overload signs are:
● Cardiovascular overload
● Pulmonary edema ● ACS (Acute Coronary Syndrome)- sudden reduced blood flow to the heart ● Monitor for adequate UOP (output), changes in mental status, skin perfusion and changes in VS ● Check for adventitious lung sounds such as crackles ● Monitor for other s/s of interstitial edema like increased work of breathing
A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply. A) Hypovolemia B) Difficulty breathing C) Cardiovascular overload
D) Pulmonary edema E) Hypoglycemia
Ans: B, C, D Feedback: Fluid replacement complications can occur, often when large volumes are administered rapidly. Therefore, the nurse monitors the patient closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement
● Venous return is decreased ● Distributive shock occurs when intravascular volume pools in peripheral blood vessels. The abnormal displacement of intravascular volume causes a relative hypovolemia because not enough blood returns to the heart which leads to inadequate tissue perfusion. ● Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased BP and ultimately decre ased tissue perfusion
When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the pooling of blood in the periphery leads to what pathophysiological effect? A) Increased stroke volume B) Increased cardiac output C) Decreased heart rate D) Decreased venous return
Ans: D Feedback: Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.
● Neurogenic, septic, and Anaphylactic shock
A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply. A) Anaphylactic B) Hypovolemic C) Cardiogenic D) Septic E) Neurogenic
Ans: A, D, E Feedback: The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of circulatory shock
● 3 defining characteristics ○ [1]Acute onset of symptoms ○ [2]Presence of 2 or more symptoms that include respiratory compromise, reduce BP, GI distress and skin or mucosal irritation ○ [3]Cardiovascular compromise from minutes to hours after the exposure ○ Onset of s/s can be from after 2 mins to 30 mins of exposure. The pt can complain of H/A, lightheadedness, N/V, acute abdominal pain, pruritus or discomfort and feeling of impending doom ○ Additional assessment may reveal erythema, generalized flushing, difficulty breathing, laryngeal edema, bronchospasms, cardiac dysrhythmias or hypotension ○ Characteristics of SEVERE anaphylactic shock include rapid onset of HYPOtension,wheezing, swelling of the pharynx, neurological compromise, respiratory arrest and cardiac arrest
A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boy’s mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock? A) Rapid onset of acute hypertension B) Rapid onset of respiratory distress C) Rapid onset of neurologic compensation D) Rapid onset of cardiac arrest
Ans: B Feedback: Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur if prompt treatment is not provided
○ Given to help improve the pt’s hemodynamic status when fluid therapy alone cannot maintain adequate mean arterial pressure (MAP) ■ Increase the strength of myocardial output ■ Regulate HR ■ Reduce myocardial resistance ■ Initiate vasoconstriction
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? A) To prevent the formation of infarcts of emboli B) To limit stroke volume and cardiac output C) To prevent pulmonary and peripheral edema D) To maintain adequate mean arterial pressure
Ans: D Feedback: Vasoactive medications can be administered in all forms of shock to improve the patient’s hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.
● Vasoactive medications should be given via a central line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing
TB QUESTION
The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way? A) Through a central venous line B) By a gravity infusion IV set
C) By IV push for rapid onset of action D) Mixed with parenteral feedings to balance osmosis
Ans: A Feedback: Whenever possible, vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition.
● Abdominal compartment syndrome is the complication ● Hypovolemic shock is characterized by decreased intravascular volume. It can be external loss (blood loss) or internal (dehydration, severe edema, or ascites). ● The primary concern is to replace fluid loss: at least 2 large gauge IV line is inserted and if an IV catheter cannot be inserted fast enough an intraosseous catheter (sternum, legs, or arms) can be inserted to facilitate rapid fluid replacement. ● If hypovolemia is primarily due to blood loss use 3mL of crystalloid to 1mL blood loss ● Place patient in modified trendelenburg with the legs slightly elevated.
TB QUESTION
The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the patient? A) Anaphylaxis B) Decreased oxygen consumption C) Abdominal compartment syndrome D) Decreased serum osmolality.
Ans: C Feedback: Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are administered. The scenario does not describe an antigen– antibody reaction of any type. Decreased oxygen consumption by the body is not a concern in hypovolemic shock. With a decrease in fluids in the intravascular space, increased serum osmolality would occur.
TB QUESTION
The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? A) Lactated Ringer’s B) Albumin C) Dextran
D) 3% NaCl
Ans: A Feedback: Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer’s and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic.
You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient? A) Hypothermia B) Bradycardia C) Coffee ground emesis D) Pain
Feedback: Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the patient for cardiovascular overload and pulmonary edema when large volumes of IV solution are administered. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock.
irreversible shock stage
○ Family needs to be informed about the prognosis and likely outcome ■ Provide opportunities for family and loved ones to see, touch, provide care and talk to the patient ■ Address any living wills, advanced directives or any other written or verbal wishes the patient may have ■ The family may misinterpret the health care team because they continue to provide care for the pt after the family has been told that nothing can be done and no tx has been effective but survival is highly unlikely ● Explain equipment and tx being provided will provide comfort to the pt
The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? A) Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock. B) Inform the patient’s family immediately that the patient will likely not survive to allow the family time to make plans and move forward. C) Closely monitor fluid replacement therapy, and inform the family that the patient will probably survive and return to normal life. D) Protect the patient’s airway, optimize intravascular volume, and initiate the early rehabilitation process.
Ans: A Feedback: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention.
TB QUESTION
A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patient’s care? A) Communicate clearly and frequently with the patient’s family. B) Taper down interventions slowly when the prognosis worsens. C) Transfer the patient to a subacute unit when recovery appears unlikely. D) Ask the patient’s family how they would prefer treatment to proceed.
Ans: A Feedback: As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the patient’s care, for the family to see, touch, and talk to the patient. The onus should not be placed on the family to guide care, however. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The patient would not be transferred to a subacute unit.
● Frequent oral care, every 4 hours ● Aseptic suction technique ● Turning the patient ● Raising the HOB 30 degrees to prevent aspiration ● Implementing daily interruption of sedation as rxed (prescribe) to evaluate patient readiness for extubation.
TB QUESTION
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patient’s plan of care while the patient is ventilated? A) Performing frequent oral care B) Maintaining the patient in a supine position C) Suctioning the patient every 15 minutes unless contraindicated D) Administering prophylactic antibiotics, as ordered
Ans: A Feedback: Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.
neurogenic shock – laboratory alterations (ALL THAT APPLY)
When MAP (mean arterial pressure) falls below 65 mmHg the GFR of the kidney cannot be maintained and acute kidney injury occurs
○ Increase BUN ○ Increase serum creatinine ○ Electrolyte shifts ○ Acid base imbalance ○ UOP decreases ○ Decreased GFR
A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patient’s mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. A) Blood urea nitrogen (BUN) level B) Urine specific gravity C) Alkaline phosphatase level D) Creatinine level E) Serum albumin level
Ans: A, B, D Feedback: Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acid–base imbalances, and a loss of the renal– hormonal regulation of BP. Urine specific gravity is also affected. Alkaline phosphatase and albumin levels are related to hepatic function
infection
● Most common cause is gram negative bacteria (antibiotic has to be effective on gram negative bacteria) ● Urosepsis is more frequent in older adult clients due to increased use of catheters in long term care facilities or they have decreased sensation of the burning.
Septic shock is caused by widespread infection or sepsis, mostly acquired in the hospital and can include bacteremia, pneumonia and urosepsis
○ Use strict infection control practices ■ Hand hygiene ■ Ensuring central line infection by removing invasive devices no longer necessary ■ Implementing prevention programs to prevent ventilator associated events and pneumonia ■ Promoting early ambulation ■ Carrying out standard precautions (aseptic technique and proper cleaning of equipment)
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient’s infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient’s risk of septic shock? A) Apply an antibiotic ointment to the patient’s mucous membranes, as ordered. B) Perform passive range-of-motion exercises unless contraindicated C) Initiate total parenteral nutrition (TPN) D) Remove invasive devices as soon as they are no longer needed.
Ans: D Feedback: Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.
○ Permit the long term use of mechanical ventilation
● A tracheostomy may either be temporary or permanent. It is used to bypass an upper airway obstruction, allow removal of tracheal- bronchial secretions, PERMIT THE LONG TERM USE OF MECHANICAL VENTILATION, prevent secretions of oral or gastric secretions in the unconscious or paralyzed patient and to replace an endotracheal tube
What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy? A) A patient has a respiratory rate of 10 breaths per minute. B) A patient requires permanent ventilation. C) A patient exhibits symptoms of dyspnea. D) A patient has respiratory acidosis. Ans: B Feedback: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.
○ Chest drainage systems are used in the postoperative period to improve gas exchange and breathing ○ Closed drainage system to re-expand the involved lung ○ Removed excess air, water and blood ○ Can also be used in the tx of pneumothorax or trauma resulting in pneumothorax
Chest drains also known as under water sealed drains (UWSD) are inserted to allow draining of the pleural spaces of air, blood or fluid, allowing expansion of the lungs and restoration of negative pressure in the thoracic cavity. The underwater seal also prevents backflow of air or fluid into the pleural cavity.
TB QUESTION
A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find?* A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.
You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention?
A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.
The assessment findings are normal. All the other options are incorrect.
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A) Maintaining positive chest-wall pressure B) Monitoring pleural fluid osmolarity C) Providing positive intrathoracic pressure D) Removing excess air and fluid.
Feedback: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure
● Anterior chest wall → remove air from the pleural space. ● Posterior chest tube → to remove fluid from the pleural cavity
A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.
TB QUESTION
What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor below that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.
TB QUESTION
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A) To remove air from the pleural space B) To drain copious sputum secretions C) To monitor bleeding around the lungs D) To assist with mechanical ventilation.
Feedback: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.
ventilation EVERY 8 hr.
Mechanical ventilation is required
● to control the patient’s respirations during surgery or treatment to oxygenate the blood when the patient’s ventilatory efforts are inadequate to rest the respiratory muscles. ● Many patients placed on a ventilator can breathe spontaneously, although the effort needed to do so may be exhausting. ○ Pressure should be maintained between 20 to 25 mmHg because high pressure cuffs can cause tracheal bleeding, ischemia, and pressure necrosis. Low pressure cuffs can cause aspiration pneumonia ○ Routine deflation of the cuff is NOT recommended because of the risk of aspiration and hypoxia ○ Check the cuff pressure every 6-8 hours
The medical nurse is creating the care plan of an adult pt requiring mechanical ventilation. What nursing action is most appropriate?
A. Keep the pt in a low Fowlers position B. Perform tracheostomy care at least once per day C. Maintain continuous bedrest D. Monitor cuff pressure every 8 hours Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowlers position is not indicated.
TB QUESTION The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? A) Deflate the cuff overnight to prevent tracheal tissue trauma. B) Inflate the cuff to the highest possible pressure in order to prevent aspiration. C) Monitor the pressure in the cuff at least every 8 hours D) Keep the tracheostomy tube plugged at all times.
C Feedback: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.
25,26. Know most important assessment parameters when weaning off a patient from
mechanical ventilation (TWO QUESTIONS)
Hyperoxygenate
Intermediate suctioning after putting catheter in
Reoxygenate
Auscultate lungs (if they are clear that's good)
Parameters to compare: vital signs,Monitor ECG, and O2, and breath sounds, and color
before intubating and then comparing them to after intubating
Pre intubation:
Preoxygenate with 100% oxygen
Sedate the patient if needed before intubating
Post intubation:
Assess bilateral breath sounds, symmetric chest movement, chest x-ray, secure
endotracheal tube, assess the balloon cuff for air leak periodically (balloon will be working as
a seal)
Exam question: When do you need tracheostomy? When intubation is expected to last a
long time. If the balloon is properly placed, the patient will not be able to talk.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning
D) Electrocardiogram (ECG) results
B Feedback: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patient's record, and the nurse can refer to them before the weaning process begins.
The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan? A) Administration of inhaled corticosteroids B) Assessment of neurologic status C) Turning and coughing D) Signs of pulmonary infection D Feedback: The nurse teaches the patient and family about the ventilator, suctioning, tracheostomy care, signs of pulmonary infection, cuff inflation and deflation, and assessment of vital signs. Neurologic assessment and turning and coughing are less important than signs and symptoms of infection. Inhaled corticosteroids may or may not be prescribed.
TB QUESTION The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness
A Feedback: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Patients who are weaned may or may not have full level of consciousness.
QUESTIONS).