A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question?
A) Give PRN furosemide (Lasix) 40 mg IV.
B) Increase normal saline infusion to 250 mL/hr.
C) Administer hydrocortisone (Solu-Cortef) 100 mg IV.
D) Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
Answer: A
A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question?
A) Infuse normal saline at 250 mL/hr.
B) Keep head of bed elevated to 30 degrees.
C) Hold nitroprusside (Nipride) if systolic BP <90 mm Hg.
D) Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
Answer: A
A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
A) Inspiratory crackles.
B) Cool, clammy extremities.
C) Apical heart rate 45 beats/min.
D) Temperature 101.2 F (38.4 C).
Answer: C
An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next?
A) Increase the rate for the dopamine (Intropin) infusion.
B) Decrease the rate for the nitroglycerin (Tridil) infusion.
C) Increase the rate for the sodium nitroprusside (Nipride) infusion.
D) Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.
Answer: C
After receiving 2 L 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 an order for
A) nitroglycerine (Tridil).
B) norepinephrine (Levophed).
C) sodium nitroprusside (Nipride).
D) methylprednisolone (Solu-Medrol).
Answer: B
To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?
A) Auscultate bowel sounds.
B) Palpate for abdominal pain.
C) Ask the patient about nausea.
D) Check stools for occult blood.
Answer: D
A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication?
A) 5% human albumin
B) Furosemide (Lasix) IV
C) Epinephrine (Adrenalin) drip
D) Hydrocortisone (Solu-Cortef)
Answer: B
The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain
A) hypothermia blanket.
B) lactated Ringers solution.
C) two 14-gauge IV catheters.
D) dopamine (Intropin) infusion.
Answer: C
Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective?
A) Hemoglobin is within normal limits.
B) Urine output is 60 mL over the last hour.
C) Central venous pressure (CVP) is normal.
D) Mean arterial pressure (MAP) is 72 mm Hg.
Answer: B
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
A) Check temperature every 2 hours.
B) Monitor breath sounds frequently.
C) Maintain patient in supine position.
D) Assess skin for flushing and itching.
Answer: B
Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?
A) The patients central venous pressure is 3 mm Hg.
B) The patient is in sinus tachycardia at 120 beats/min.
C) The patient is receiving low dose dopamine (Intropin).
D) The patient has had no urine output since being admitted.
Answer: A
A 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 new heart murmurs
B) Decreased troponin level
C) Warm, pink, and dry skin
D) Blood pressure 92/40 mm Hg
Answer: C
Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?
A) Heart rate
B) Orientation
C) Blood pressure
D) Oxygen saturation
Answer: D
Which data collected by the nurse caring for a patient who has cardiogenic shock indicate 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 patients extremities are cool and pulses are weak.
D) The patient has bilateral crackles throughout lung fields.
Answer: A
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 intervention ordered by the health care provider should the nurse implement first?
A) Give normal saline IV at 500 mL/hr.
B) Give acetaminophen (Tylenol) 650 mg rectally.
C) Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
D) Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.
Answer: A
When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?
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) Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
D) Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock
Answer: D
The nurse is 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) Blood pressure (BP) 92/56 mm Hg
B) Skin cool and clammy
C) Oxygen saturation 92%
D) Heart rate 118 beats/minute
Answer: B
A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
A) administer oxygen.
B) obtain a 12-lead electrocardiogram (ECG).
D) obtain the blood pressure.
D) check the level of consciousness.
Answer: A
During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?
A) New onset of confusion
B) Heart rate 112 beats/minute
C) Decreased bowel sounds
D) Pale, cool, and dry extremities
Answer: A
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first?
A) Insert two large-bore IV catheters.
B) Initiate continuous electrocardiogram (ECG) monitoring.
C) Provide oxygen at 100% per non-rebreather mask.
D) Draw blood to type and crossmatch for transfusions
Answer: C
The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?
A) The patients heart rate is 58 beats/minute.
B) The patients extremities are warm and dry.
C) The patients IV infusion site is cool and pale.
D) The patients urine output is 28 mL over the last hour.
Answer: C
The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?
A) Start a normal saline infusion.
B) Give epinephrine (Adrenalin).
C) Start continuous ECG monitoring.
D) Give diphenhydramine (Benadryl).
Answer: B
Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider?
A) The patients urine output is 18 mL/hr.
B) The patients heart rate is 110 beats/minute.
C) The patient is complaining of chest pain.
D) The patients peripheral pulses are weak.
Answer: C
After change-of-shift report in the progressive care unit, who should the nurse care for first?
A) Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases
B) who has new orders for urine and blood cultures and antibiotics
C) Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute
D) Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg
Answer: B