Nursing Management: Shock & MODS (NCLEX)

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
a. check the blood pressure.
b. obtain an oxygen saturation.
c. attach a cardiac monitor.
d. check level of consciousness.
1.Correct Answer: B
Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.
2. A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the
a. progressive stage of septic shock.
b. compensatory stage of diabetic shock.
c. refractory stage of cardiogenic shock.
d. progressive stage of hypovolemic shock.
Correct Answer: D
Rationale: The patient’s history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with hypovolemia, and the symptoms are most consistent with the progressive stage of shock. The patient’s temperature of 97° F is inconsistent with septic shock. The history is inconsistent with a diagnosis of cardiogenic shock, and the patient’s neurologic status is not consistent with refractory shock.
3. A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is
a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries.
b. stimulation of cardiac -adrenergic receptors, leading to increased cardiac output.
c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.
d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.
Correct Answer: C
Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.
4. While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding
a. cold, mottled extremities.
b. restlessness and apprehension.
c. a heart rate of 120 and cool, clammy skin.
d. systolic BP less than 90 mm Hg.
Correct Answer: B
Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.
5. When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the
a. cardiac output is increased and the central venous pressure (CVP) is low.
b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low.
c. heart rate is decreased, and the systemic vascular resistance is low.
d. cardiac output is decreased and the PAWP is high.
Correct Answer: A
Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.
6. A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?
a. Insert two 14-gauge IV catheters.
b. Administer oxygen at 100% per non-rebreather mask.
c. Place the patient on continuous cardiac monitor.
d. Draw blood to type and crossmatch for transfusions.
Correct Answer: B
Rationale: 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 should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.
7. A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of
a. cool, clammy skin.
b. shortness of breath.
c. heart rate of 48 beats/min
d. BP of 82/40 mm Hg.
Correct Answer: C
Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.
8. The nurse caring for a patient in shock notifies the health care provider of the patient’s deteriorating status when the patient’s ABG results include
a. pH 7.48, PaCO2 33 mm Hg.
b. pH 7.33, PaCO2 30 mm Hg.
c. pH 7.41, PaCO2 50 mm Hg.
d. pH 7.38, PaCO2 45 mm Hg.
Correct Answer: B
Rationale: The patient’s low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning “pH 7.48” suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning “pH 7.41” suggest compensated respiratory acidosis. The values in the answer beginning “pH 7.38” are normal.
9. 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 patient has an apical pulse rate of 58 beats/min.
b. The patient’s urine output has been 28 ml over the last hour.
c. The patient’s IV infusion site is cool and pale.
d. The patient has warm, dry skin on the extremities.
Correct Answer: C
Rationale: The coldness and pallor at the infusion site suggest extravasation of the Neo-Synephrine. 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 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 indicates that the patient is in early neurogenic shock.
10. A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of
a. nitroglycerine (Tridil).
b. dobutamine (Dobutrex).
c. norepinephrine (Levophed).
d. sodium nitroprusside (Nipride).
Correct Answer: C
Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.
11. A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)?
a. Administer all medications through the patient’s indwelling central line.
b. Place the patient in a private room.
c. Restrict the patient to foods that have been well-cooked or processed.
d. Insert a nasogastric (NG) tube for enteral feeding.
Correct Answer: B
Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient’s nausea and vomiting.
12. All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who develops severe respiratory distress and faintness. Which one will the nurse administer first?
a. Epinephrine (Adrenalin)
b. Normal saline infusion
c. Dexamethasone (Decadron)
d. Diphenhydramine (Benadryl)
Correct Answer: A
Rationale: 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 are also appropriate but would not be the first ones administered.
13. A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate
a. administration of furosemide (Lasix) IV.
b. titration of an epinephrine (Adrenalin) drip.
c. administration of a normal saline bolus.
d. assisting with endotracheal intubation.
Correct Answer: A
Rationale: The PAWP indicates that the patient’s preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase myocardial oxygen demand and might extend the MI. The PAWP is already elevated, so normal saline boluses would be contraindicated. There is no indication that the patient requires endotracheal intubation.
15. The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient’s
a. urine output is 40 ml over the last hour.
b. hemoglobin is within normal limits.
c. CVP has decreased.
d. mean arterial pressure (MAP) is 65 mm Hg.
Correct Answer: A
Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.
16. The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy?
a. The patient is restless and anxious.
b. The patient has a heart rate of 134.
c. The patient has hypotonic bowel sounds.
d. The patient has a temperature of 94.1° F.
Correct Answer: D
Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.
17. Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the drug, the nurse ensures that the
a. patient’s heart rate is less than 100.
b. patient has received adequate fluid replacement.
c. patient’s urine output is within normal range.
d. patient is not receiving other sympathomimetic drugs.
Correct Answer: B
Rationale: If vasoconstrictors are given in a hypovolemic patient, the peripheral vasoconstriction will further decrease tissue perfusion. A patient with hypovolemia is likely to have a heart rate greater than 100 and a low urine output, so these values are not contraindications to vasoconstrictor therapy. Patients may receive other sympathomimetic drugs concurrently with Levophed.
18. When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and nitroglycerin (Tridil) infusions, the best evidence that the medications are effective is that the
a. systolic BP increases to greater than 100 mm Hg.
b. cardiac monitor shows sinus rhythm at 96 beats/min.
c. PAWP drops to normal range.
d. troponin and creatine kinase levels decrease.
Correct Answer: C
Rationale: Because PAWP is increased in cardiogenic shock as a result of the increase in volume and pressure in the left ventricle, normalization of PAWP is the best indicator of patient improvement. The changes in BP and heart rate could occur with dobutamine infusion even if patient tissue perfusion was not improved. Troponin and creatine kinase (CK) levels are indicators of cardiac cellular death and are not used as indicators of improved tissue perfusion.
19. While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient’s bed is elevated to 75 degrees. This finding indicates a need for
a. additional fluid replacement.
b. antibiotic administration.
c. infusion of a sympathomimetic drug.
d. administration of increased oxygen.
Correct Answer: A
Rationale: A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions. There are no data to suggest that antibiotics, sympathomimetics, or additional oxygen are needed.
20. The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to
a. arrange for the hospital pastoral care staff to visit the patient.
b. ask the health care provider to prescribe a sedative drug for the patient.
c. leave the patient alone with family members whenever possible.
d. place the patient’s call bell where it can be easily reached.
Correct Answer: D
Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff should be asked to visit only after checking with the patient to determine whether this is desired. Providing time for family to spend with the patient is appropriate, but patients and family should not feel that the nurse is unavailable. Sedative administration is helpful but does not as directly address the patient’s anxiety about dying.
21. A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is
a. urine output of 0.5 ml/kg/hr.
b. decreased peripheral edema.
c. decreased CVP.
d. oxygen saturation 90% or more.
Correct Answer: A
Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.
22. A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first?
a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl.
b. Give normal saline IV at 500 ml/hr.
c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg.
d. Infuse drotrecogin- (Xigris) 24 mcg/kg.
Correct Answer: B
Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions are also appropriate and should be initiated quickly as well.
23. A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock?
a. The cardiac output is elevated.
b. The central venous pressure (CVP) is increased.
c. The systemic vascular resistance (SVR) is high.
d. The PAWP is high.
Correct Answer: A
Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.
24. When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS?
a. The patient has crackles throughout both lung fields.
b. The patient complains of 8/10 crushing chest pain.
c. The patient has an elevated ammonia level and confusion.
d. The patient has cool extremities and weak pedal pulses.
Correct Answer: C
Rationale: The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure. The crackles, chest pain, and cool extremities are all consistent with cardiogenic shock and do not indicate that there are failures in other major organ systems.
25. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are
a. stool guaiac and bowel sounds.
b. lung sounds and oxygenation status.
c. serum creatinine and urinary output.
d. serum bilirubin levels and skin color.
Correct Answer: B
Rationale: The respiratory system is usually the system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.
26. An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes
a. respiratory rate of 10 breaths/min.
b. fixed urine specific gravity at 1.010.
c. MAP of 55 mm Hg.
d. 360-ml urine output in 8 hours.
Correct Answer: B
Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular necrosis. With MODS, the patient’s respiratory rate would initially increase. The MAP of 55 shows continued shock, but not necessarily progression to MODS. A 360-ml urine output over 8 hours indicates adequate renal perfusion.
27. When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse?
a. BP 88/56 mm Hg
b. Apical pulse 110 beats/min
c. Urine output 15 ml for 2 hours
d. Arterial oxygen saturation 90%
Correct Answer: C
Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.