Chapter 67: Nursing Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 67: Nursing Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome

Test Bank

MULTIPLE CHOICE

1. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question?

a.

Give furosemide (Lasix) 40 mg IV.

b.

Increase normal saline infusion to 150 mL/hr.

c.

Administer hydrocortisone (SoluCortef) 100 mg IV.

d.

Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.

ANS: A

Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.

DIF: Cognitive Level: Application REF: 1724-1726 | 1731 | 1733

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question?

a.

Infuse normal saline at 250 mL/hr.

b.

Keep head of bed elevated to 30 degrees.

c.

Give nitroprusside (Nipride) unless systolic BP <90 mm Hg.

d.

Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

ANS: A

The patients elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.

DIF: Cognitive Level: Application REF: 1719 | 1721-1722 | 1735

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

3. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?

a.

Cool, clammy skin

b.

Inspiratory crackles

c.

Apical heart rate 48 beats/min

d.

Temperature 101.2 F (38.4 C)

ANS: C

Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

DIF: Cognitive Level: Comprehension REF: 1721-1722 | 1723

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking?

a.

Increase the rate for the prescribed dopamine (Intropin) infusion.

b.

Decrease the rate for the prescribed nitroglycerin (Tridil) infusion.

c.

Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion.

d.

Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.

ANS: D

Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR.

DIF: Cognitive Level: Application REF: 1733-1734 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

5. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of

a.

nitroglycerine (Tridil).

b.

drotrecogin alpha (Xigris).

c.

norepinephrine (Levophed).

d.

sodium nitroprusside (Nipride).

ANS: C

When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR.

DIF: Cognitive Level: Application REF: 1731 | 1733-1735

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse make?

a.

Auscultate bowel sounds.

b.

Ask the patient about nausea.

c.

Monitor stools for occult blood.

d.

Check for abdominal distention.

ANS: C

Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the omeprazole administration.

DIF: Cognitive Level: Application REF: 1735-1737 | 1742-1743

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

7. A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate

a.

infusion of 5% human albumin.

b.

administration of furosemide (Lasix) IV.

c.

titration of an epinephrine (Adrenalin) drip.

d.

administration of hydrocortisone (SoluCortef).

ANS: B

The PAWP indicates that the patients preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. Normal saline infusion would increase the PAWP further. Hydrocortisone might be used for septic or anaphylactic shock.

DIF: Cognitive Level: Application REF: 1735 | 1736 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

8. The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain

a.

500 mL of 5% albumin.

b.

lactated Ringers solution.

c.

two 14-gauge IV catheters.

d.

dopamine (Intropin) infusion.

ANS: C

A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringers solution should be used cautiously and will not be ordered until the patient has 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 MSC: NCLEX: Physiological Integrity

9. Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful?

a.

Hemoglobin is within normal limits.

b.

Urine output is 60 mL over the last hour.

c.

Pulmonary artery wedge pressure (PAWP) is normal.

d.

Mean arterial pressure (MAP) is 65 mm Hg.

ANS: B

Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

DIF: Cognitive Level: Application REF: 1733-1735 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

a.

Avoid elevating head of bed.

b.

Check temperature every 2 hours.

c.

Monitor breath sounds frequently.

d.

Assess skin for flushing and itching.

ANS: C

Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated 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: Implementation MSC: NCLEX: Physiological Integrity

11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine?

a.

The patients central venous pressure is 3 mm Hg.

b.

The patient is receiving low dose dopamine (Intropin).

c.

The patient is in sinus tachycardia at 100 to 110 beats/min.

d.

The patient has had no urine output since being admitted.

ANS: A

Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patients low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

DIF: Cognitive Level: Application REF: 1733-1735 | 1736

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective?

a.

No heart murmur is audible.

b.

Skin is warm, pink, and dry.

c.

Troponin level is decreased.

d.

Blood pressure is 90/40 mm Hg.

ANS: B

Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

DIF: Cognitive Level: Application REF: 1721 | 1723 | 1733-1735

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

13. Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective?

a.

Pulse rate

b.

Orientation

c.

Blood pressure

d.

Oxygen saturation

ANS: D

Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments also will be expected with effective treatment of anaphylactic shock.

DIF: Cognitive Level: Application REF: 1724-1725 | 1732

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

14. Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)?

a.

The patients serum creatinine level is elevated.

b.

The patient complains of intermittent chest pressure.

c.

The patient has crackles throughout both lung fields.

d.

The patients extremities are cool and pulses are weak.

ANS: A

The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patients diagnosis of cardiogenic shock.

DIF: Cognitive Level: Application REF: 1740-1741

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first?

a.

Give normal saline IV at 500 mL/hr.

b.

Infuse drotrecogin-a (Xigris) 24 mcg/kg.

c.

Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.

d.

Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.

ANS: A

Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

DIF: Cognitive Level: Application REF: 1735-1737

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

16. When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock?

a.

Placing the pulse oximeter on the ear for a patient with septic shock

b.

Keeping the head of the bed flat for a patient with hypovolemic shock

c.

Decreasing the room temperature to 68 F for a patient with neurogenic shock

d.

Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR

ANS: C

Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

DIF: Cognitive Level: Application REF: 1721-1722 | 1724

OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment

17. When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider?

a.

BP 92/56 mm Hg

b.

Skin cool and clammy

c.

Apical pulse 118 beats/min

d.

Arterial oxygen saturation 91%

ANS: B

Since patients in the early stage of septic shock have warm and dry skin, the patients cool and clammy skin indicates that shock is progressing. The other information also will be reported, but does not indicate deterioration of the patients status.

DIF: Cognitive Level: Application REF: 1723

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

18. A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to

a.

administer oxygen.

b.

attach a cardiac monitor.

c.

obtain the blood pressure.

d.

check the level of consciousness.

ANS: A

The initial actions of the nurse are focused on the ABCsairway, breathing, circulationand administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.

DIF: Cognitive Level: Application REF: 1729-1731 | 1732 | 1733 | 1736-1737

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

19. During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider?

a.

Decreased bowel sounds

b.

Apical pulse 110 beats/min

c.

Pale, cool, and dry extremities

d.

New onset of confusion and agitation

ANS: D

The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

DIF: Cognitive Level: Application REF: 1728-1729

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

20. A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first?

a.

Place the patient on continuous cardiac monitor.

b.

Draw blood to type and crossmatch for transfusions.

c.

Insert two 14-gauge IV catheters in antecubital space.

d.

Administer oxygen at 100% per non-rebreather mask.

ANS: D

The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions also should be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.

DIF: Cognitive Level: Application REF: 1732

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

21. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action?

a.

The patients IV infusion site is cool and pale.

b.

The patient has warm, dry skin on the extremities.

c.

The patient has an apical pulse rate of 58 beats/min.

d.

The patients urine output has been 28 mL over the last hour.

ANS: A

The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28 mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

DIF: Cognitive Level: Application REF: 1733-1734

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

22. The following therapies are prescribed by the health care provider for a patient who has respiratory distress and syncope after a bee sting. Which will the nurse administer first?

a.

normal saline infusion

b.

epinephrine (Adrenalin)

c.

dexamethasone (Decadron)

d.

diphenhydramine (Benadryl)

ANS: B

Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions also are appropriate but would not be the first ones administered.

DIF: Cognitive Level: Application REF: 1736-1737

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

23. Which information about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the heath care provider?

a.

The patients heart rate is 108 beats/min.

b.

The patient is complaining of chest pain.

c.

The patients peripheral pulses are weak.

d.

The patients urine output is 15 mL/hr.

ANS: B

Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patients diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy.

DIF: Cognitive Level: Application REF: 1735-1736

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take (select all that apply)?

a.

Prepare to administer atropine IV.

b.

Obtain baseline body temperature.

c.

Prepare for intubation and mechanical ventilation.

d.

Administer large volumes of lactated Ringers solution.

e.

Administer high-flow oxygen (100%) by non-rebreather mask.

ANS: A, B, C, E

All of the actions are appropriate except to give large volumes of lactated Ringers solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringers solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.

DIF: Cognitive Level: Application REF: 1736-1737

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

COMPLETION

1. The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

a. Obtain blood and urine cultures.

b. Give vancomycin (Vancocin) 1 g IV.

c. Infuse vasopressin (Pitressin) 0.01 units/min.

d. Administer normal saline 1000 mL over 30 minutes.

e. Titrate oxygen administration to keep O2 saturation >95%.

ANS:

E, D, C, A, B

The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.

DIF: Cognitive Level: Analysis REF: 1735-1737

OBJ: Special Questions: Alternate Item Format, Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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