Test Bank Chapter 34 Critical Care of Patients With Shock Ignatavicius Medical-Surgical Nu, Exams of Nursing

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Test Bank Chapter 34 Critical Care of

Patients With Shock Ignatavicius

Medical-Surgical Nursing, 10th Edition

A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP. - ANS: b. Lower blood volume lowers MAP. ANS: B Lower blood volume will decrease MAP. The other answers are not accurate A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess using the MEWS score. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion. - ANS: b. Assess using the MEWS score. ANS: B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse would conduct a thorough assessment of the patient, focusing on indicators of perfusion. The MEWS score (Modified Early Warning Score) was developed to identify clients at risk for deterioration. The client may need pain medication, but this is not the priority at this time. Documentation would be done thoroughly but would be done after the assessment. The nurse would not increase the rate of the IV infusion without an order The nurse gets the hand-off report on four clients. Which client would the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg

b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours - ANS: a. Client with a blood pressure change of 128/74 to 110/88 mm Hg This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowingpulse pressure, all of which may be indications of worsening perfusion status and possibleshock. The nurse would assess this client first. The client with the unchanged oxygensaturation is stable at this point. Although the client with a change in pulse has a slower rate, itis not an indicator of shock since the pulse is still within the normal range; it may indicate thatthe client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urineoutput of 40 mL/hr is above the normal range, which is 30 mL/hr. A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the side. d. Stay with the client and reassure him or her - ANS: b. Measure urine output from the catheter.. ANS: B Urine output changes are a sensitive early indicator of shock. The nurse would delegate emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine output measurements. The AP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments.Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic. - ANS: a. "High glucose is common in shock and needs to be treated."

High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L.Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3(3. 109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6°C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the primary health care provider immediately. d. Prepare to administer insulin per sliding scale. - ANS: c. Notify the primary health care provider immediately. This client has several indicators of sepsis with systemic inflammatory response. The nurse would notify the primary health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may need insulin if blood glucose is being regulated tightly. A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations d. Take medications as prescribed. - ANS: b. Drink fluids on a regular schedule. Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn't give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse take priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain a pulse oximetry reading d. Start two large-bore IV catheters. - ANS: b. Ensure the client has a patent airway. ANS: B Airway is the priority, followed by breathing (pulse oximetry) and circulation (IVs and direct pressure) A client is receiving nor-epinephrine for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denies chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours - ANS: a. Alert and oriented, answering questions Normal cognitive function is a good indicator that the client is receiving the benefits of nor-epinephrine. The brain is very sensitive to changes in oxygenation and perfusion.Nor-epinephrine can cause chest pain as an adverse reaction, so the absence of chest pain is good but does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so. A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome(MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the nurse causes the charge nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable ("smart") IV pump. c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vitals. - ANS: c. Removing the IV bag from the brown plastic cover

Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct A nurse on the medical-surgical unit is caring for a client in shock and assesses the following:Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/78 mm Hg Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C)Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best? a. Transfer the client to the Intensive Care Unit. b. Continue monitoring every 30 minutes. c. Notify the unit charge nurse immediately. d. Call the Rapid Response Team - ANS: d. Call the Rapid Response Team This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1, UO: 1). Scores above 5 are associated with a high risk of death and ICU admission. The most important action for the nurse is to notify the Rapid Response Team so that timely interventions can be initiated. The client most likely will be transferred to the ICU, but an order is required. Monitoring the client every 30 minutes is appropriate, but the nurse needs to obtain care for the client. The charge nurse is a valuable resource, but the best action is to notify the Rapid Response Team. A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the primary health care provider? a. Creatinine: 0.9 mg/dL (68.6 mcmol/L) b. Lactate: 5.4 mg/dL (6 mmol/L) c. Sodium: 150 mEq/L (150 mmol/L) d. White blood cell count: 11,000/mm3 (11 109/L) - ANS: b. Lactate: 5.4 mg/dL (6 mmol/L) A lactate level of 5.4 mg/dL (6 mmol/L) is high and is indicative of possible shock. Acreatinine level of 0. mg/dL (68.6 mcmol/L) is normal. A sodium level of 150 mEq/L (150mmol/L) is slightly high but does not need to be communicated. A white blood cell count of11,000/mm3 (11 109/L) is slightly high but is not as critical as the lactate level. A nurse receives hand-off report from the emergency department on a new admission suspected of having septic shock. The client's qSOFA score is 3. What action by the nurse is best? a. Plan to calculate a full SOFA score on arrival.

b. Contact respiratory therapy about ventilator setup. c. Arrange protective precautions to be implemented. d. Call the hospital chaplain to support the family - ANS: a. Plan to calculate a full SOFA score on arrival. The qSOFA score is an abbreviated Sequential Organ Failure Assessment (or "quick"). A score of 3 is high and requires the nurse to assess the client further for organ impairment. The client may or may not need a ventilator, but that in not specified in the score. The client does not need protective precautions. The client's family may well need support, but the nurse would assess their needs and wishes prior to calling the chaplain. A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's stern-al wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grand-kids are so excited to have me coming home!" - ANS: b. "I hope I can get my water turned back on when I get home." ANS: B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs.However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes. A client with MODS has been started on dobutamine. What assessment finding requires the nurse to communicate with the primary health care provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr - ANS: c. Report of chest heaviness

Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect ofdobutamine. While taking dobutamine, the oxygen requirements of the heart are increased dueto increased myocardial workload, and may cause ischemia. Without knowing the client'sprevious blood pressure or pedal pulses, there is not enough information to determine if theseare an improvement or not. A urine output of 32 mL/hr is acceptable. The nurse studying shock understands that the common signs and symptoms of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased systemic perfusion - ANS: a. Anaerobic metabolism c. Hypotension The common signs and symptoms of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function,and increased perfusion are not the cause of common signs and symptoms of shock. The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures f. Limiting the client's visitors until more stable - ANS: a. Assessing and identifying clients at risk c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures,

Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique,and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change. Limiting the client's visitors is not a caring action. The nurse would ensure they perform proper hand hygiene on entering and leaving the room and that visitors are not ill themselves The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.), a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Over hydration f. Use of diuretics - ANS: a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition f. Use of diuretics ANS: A, B, C, D, F Immobility, decreased thirst response, diminished immune response, malnutrition, and use of diuretics can place the older adult at higher risk of developing shock. Over hydration is not a common risk factor for shock.DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance - ANS: a. Bringing the client warm blankets

b. Giving the client hot tea to drink d. Reorienting the client as needed e. Sitting with the client for reassurance The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety,and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow,small amounts of fluids would be allowed. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism. The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids. - ANS: a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids. Within the first hour of suspecting severe sepsis, the nurse would draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), administer antibiotics (after the cultures have been obtained), begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. and administer vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure equal to or > 65 mm Hg. Initiating hemodynamic monitoring would be done after these "bundle" measures have been accomplished.