Chapter 54- Shock, Systemic Inflammatory Response Syndrome. My Nursing Test Banks

 

1.

What would the nurse identify as the primary purpose for the administration of intravenous (IV) crystalloid fluids in the patient with hypovolemic shock?

A)

Decrease myocardial oxygen demand.

B)

Maximize oxygen-carrying capability.

C)

Increase capillary permeability.

D)

Restore circulating volume.

2.

The nurse is administering an intravenous antibiotic infusion over 30 minutes for a patient with cellulitis of the left lower extremity. The patient states, I am itching all over and am having trouble swallowing. What priority interventions by the nurse are necessary for this patient? Select all that apply.

A)

Stop the antibiotic infusion.

B)

Administer subcutaneous epinephrine.

C)

Administer diphenhydramine (Benadryl) IV.

D)

Switch to amoxicillin by mouth.

E)

Administer Ativan for the patients anxiety.

3.

A nursing assessment of a patient with hypovolemic shock is most likely to reveal what assessment findings? Select all that apply.

A)

Tachycardia

B)

Oliguria

C)

Disoriented to time and place

D)

Diuresis

E)

Bradycardia

F)

Hypotension

4.

The nurse is assigned to the care of a patient in the ICU who is in cardiogenic shock. What priority nursing intervention is necessary to conserve myocardial energy and decrease workload of the heart?

A)

Lactated Ringers at 150 mL/hr

B)

Morphine sulfate 4 mg IV

C)

Furosemide (Lasix) 80 mg IV

D)

Epinephrine 1:1,000, 0.3 mL IV

5.

The nurse in the ICU is assigned to care for a patient with septic shock. What nursing interventions are necessary to prevent malnutrition and optimize cellular function in this patient?

A)

Administration of crystalloid solutions IV

B)

High calorie, low protein diet

C)

Enteral feedings

D)

Administration of multivitamins in the IV fluid

6.

In developing the discharge plan for a patient who was treated in the hospital for anaphylactic shock related to a nonsteroidal anti-inflammatory (NSAID) allergy, what would be the most important information for the nurse to include?

A)

Adhere to dietary restrictions.

B)

Follow up in one month with the physician.

C)

Check labels of over-the-counter medications prior to taking.

D)

Have blood pressure checked on a regular basis.

7.

The nurse is assigned to a patient in the ICU who is on a ventilator for exacerbation of chronic obstructive pulmonary disease. What intervention by the nurse can prevent the development of multiple organ dysfunction syndrome?

A)

Suctioning the patient every 2 hours

B)

Enteral feedings

C)

Oral care every 2 hours

D)

Administration of total parenteral nutrition

8.

The nurse understands that which of the following patients in the hospital is at the greatest risk for cardiogenic shock?

A)

The 76-year-old male patient with a history of diabetes mellitus and previous myocardial infarction (MI)

B)

The 42-year-old male who has mitral valve prolapse with a left ventricular ejection fraction of 65%

C)

The 52-year-old female with a recent small anteroseptal wall MI

D)

The 84-year-old female with hypertension

9.

The patient in the ICU is being treated for left lower lobe pneumonia. What assessment findings by the nurse may indicate that the patient is developing systemic inflammatory response syndrome (SIRS)? Select all that apply.

A)

White blood cell count of 24,000/mm3

B)

Respiratory rate of 24

C)

Blood pressure of 100/60

D)

Heart rate 96

E)

Atrial fibrillation

10.

The nurse is caring for a patient with hypovolemic shock who has had 6 units of packed red blood cells. Which of the following values would alert the nurse to a complication related to the administration of blood?

A)

Potassium level of 6.0

B)

Hemoglobin of 13

C)

Sodium level of 134

D)

pH 7.37

11.

A patient in the critical care unit has developed shock. What symptom or symptom group does the nurse expect to assess in any type of shock?

A)

Tissue hypoxia

B)

Massive vasodilation

C)

Extreme blood loss

D)

Presence of enterotoxins

12.

A critically ill patient has developed shock. What nursing assessment result indicates a normal compensatory mechanism?

A)

Reduction of respiratory depth

B)

Increase in systemic vascular resistance (SVR)

C)

Decrease in circulating catecholamines

D)

Increased stimulation of baroreceptors

13.

The patient is in hypovolemic shock from traumatic massive blood loss and is tachypneic and tachycardic, with cool, clammy skin and weak and thready pulses. What additional assessment parameter would the nurse be least likely to find during stage one or early compensated shock?

A)

Hypotension

B)

Increased urine output

C)

Estimated blood loss greater than 30%

D)

Mild altered mental status

14.

A patient is being treated for severe hypovolemic shock. Based on the primary treatment goal, what nursing intervention has the highest priority?

A)

Frequent measurement of vital signs

B)

Management of mechanical ventilation

C)

Rapid intravenous fluid administration

D)

Insertion of urinary drainage catheter

15.

The patient has developed cardiogenic shock and is decompensating. What pattern of hemodynamic alterations does the nurse expect to find?

A)

High preload, high afterload, low cardiac index, tachycardia

B)

Low preload, low afterload, high cardiac index, bradycardia

C)

Low preload, high afterload, high cardiac index, tachycardia

D)

High preload, low afterload, high cardiac index, tachycardia

16.

The patient is in decompensated cardiogenic shock. What collaborative intervention best addresses the central cause of cardiogenic shock?

A)

Mechanical ventilation

B)

Hemodynamic monitoring

C)

Pharmacologic sedation

D)

Intravenous nitrate infusion

17.

For a patient in cardiogenic shock, the physician has ordered an intravenous continuous infusion of dobutamine hydrochloride. What nursing assessment result demonstrates achievement of therapeutic goals?

A)

Blood pressure 120/70 mm Hg

B)

Urine output 30 to 40 mL/hr

C)

Arterial oxygen saturation 60%

D)

Heart rate 110 to 120 bpm

18.

A patient is in shock and is exhibiting low blood pressure, low systemic vascular resistance (SVR), peripheral edema, pulmonary wheezing, tachycardia, and nausea and vomiting. What precipitating event does the nurse expect for this group of symptoms?

A)

Acute myocardial infarction

B)

Bacterial infectious illness

C)

Recent seafood meal

D)

Massive fluid loss

19.

The patient has been diagnosed with shock secondary to an antigenantibody reaction. What collaborative intravenous intervention has the highest priority?

A)

Dobutamine

B)

Red blood cells

C)

Antimicrobials

D)

Epinephrine

20.

A critically ill patient has developed septic shock. What pattern of hemodynamic values does the nurse expect to find?

A)

Low preload, high afterload, low cardiac index, tachycardia

B)

Low preload and afterload, high cardiac index, tachycardia

C)

High preload and afterload, low cardiac index, tachycardia

D)

Normal preload, low afterload, normal cardiac index, bradycardia

21.

A leading cause of death in critically ill patients is sepsis and septic shock. What nursing intervention is most directed toward preventing this life-threatening complication?

A)

Strict adherence to hand hygiene protocols

B)

Prompt initiation of isolation protocols

C)

Patient and family preventive teaching

D)

Sterile technique for care of intravenous sites

22.

A patient has been diagnosed with septic shock and is receiving intravenous fluid resuscitation along with other therapies. What nursing assessment best indicates improvement in tissue perfusion?

A)

Mean arterial pressure 65 to 70 mm Hg

B)

SvO2 80% to 90%

C)

Skin warm and dry

D)

Arterial bicarbonate ion 22 to 24 mEq/L

23.

A critically ill patient who is mechanically ventilated and has developed shock is in need of nutritional support. What route is preferred for this patient?

A)

Oral

B)

Enteral

C)

Parenteral

D)

Variable

24.

A patient in shock has developed systemic inflammatory response syndrome (SIRS). What is the most likely type of shock resulting in SIRS?

A)

Hypovolemic

B)

Septic

C)

Cardiogenic

D)

Any shock

25.

A critically ill patient has developed multiple organ dysfunction syndrome (MODS). What should the nursing goal for management of the patient with impending MODS center on?

A)

Early normalization of SvO2 and acidbase balance

B)

Use of intravenous drotrecogin alfa (Xigris)

C)

Specific organ system support

D)

General intensive nursing care

Answer Key

1.

D

2.

A, B, C

3.

A, B, C, F

4.

B

5.

C

6.

C

7.

C

8.

A

9.

A, B, D

10.

A

11.

A

12.

B

13.

A

14.

C

15.

A

16.

D

17.

B

18.

C

19.

D

20.

B

21.

A

22.

D

23.

B

24.

D

25.

A

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