Nursing 5- Shock, Sepsis, and MODS W25

What medication is commonly used in the management of a patient with neurogenic shock?

a. epinephrine

b. warfarin

c. metoprolol

d. dopamine

Dopamine

rationale: helps increase blood pressure and cardiac output

A nurse is caring for a 73-year-old client in the emergency department (ED). It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

- Measure lactate level

rationale: Interventions for sepsis include identifying the problem early, correcting the cause, and preventing complications. Measuring lactate level within the first hour after client presentation or onset of sepsis manifestations is included in the resuscitative bundle to identify severity.

- Rapidly administer 30mL/kg of normal saline

rationale: Interventions for sepsis include identifying the problem early, correcting the cause, and preventing complications. A sepsis resuscitation bundle is used to prevent complications and includes rapid administration of crystalloid within the first hour after client presentation or onset of sepsis manifestations such as hypotension or a lactate level greater than or equal to 4 mmol/L.

- Obtain blood cultures

rationale: Interventions for sepsis include identifying the problem early, correcting the cause, and preventing complications. A sepsis resuscitation bundle is used to prevent complications and includes obtaining blood cultures within the first hour after client presentation or onset of sepsis manifestations. Blood cultures should be obtained before administering antibiotics to identify the specific microorganism.

- Administer broad-spectrum antibiotics

rationale: Interventions for sepsis include identifying the problem early, correcting the cause, and preventing complications. A sepsis resuscitation bundle is used to prevent complications and includes administration of broad-spectrum antibiotics after obtaining prescribed cultures, but within the first hour after client presentation or onset of sepsis manifestations. Administration of broad-spectrum antibiotics within the first hour after client presentation or onset of sepsis manifestation assists in eliminating the micro-organism until the specific organism is identified.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

"DIC is caused by abnormal coagulation involving fibrinogen"

rationale: DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.

Which intervention is a priority in the management of cardiogenic shock?

Initiating vasopressor support

rationale: Initiating vasopressor support is a priority intervention in the management of cardiogenic shock. Vasopressors help increase systemic vascular resistance and improve cardiac output.

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

a. decrease in respiratory rate from 20 to 16/min

b. decrease in urinary output from 50mL to 30mL per hour

c. increase in temperature from 37.5°C (99.5°F) to 38.6°C (101.5°F)

d. increase in the heart rate form 88 to 110/min

Increase in the heart rate from 88 to 110/min

rationale: Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock (compensatory), the heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole.

A client with advanced shock is being treated in the ICU. Which of the following interventions should the nurse implement first to manage advanced shock effectively?

a. administer a proton pump inhibitor

b. elevate HOB to 30 degrees

c. monitor urine output hourly

d. start a continuous infusion of norepinephrine

Start a continuous infusion of norepinephrine

rationale: Starting a continuous infusion of norepinephrine is critical in the management of advanced shock to maintain adequate blood pressure and perfusion to vital organs.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Blood pressure 115/68 mmHg

rationale: The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

a. urticaria

b. stridor

c. vomitting

d. hypotension

Stridor

rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance.

Which of the following is a complication of Multiple Organ Dysfunction Syndrome (MODS)?

Acute kidney injury (AKI)

rationale: Acute Kidney Injury can occur as a complication of MODS due to decreased blood flow and oxygenation to the kidneys.

A patient with multi organ dysfunction syndrome is prescribed a medication that is primarily metabolized by the liver. Which of the following statements is true regarding the administration of this medication?

a. the medication should be administered at a higher dose to compensate for reduced liver function

b. the medication should be avoided in patients with MODS

c. the medication should be administered at the usual dose, as liver is not affected by MODS

d. the medication should be administered at a lower dose to prevent liver toxicity

The medication should be administered at a lower dose to prevent liver toxicity

rationale: In multi organ dysfunction syndrome, the liver may not be functioning properly, leading to impaired metabolism of medications. Therefore, a lower dose of the medication should be administered to prevent liver toxicity.

Which of the following is a characteristic hemodynamic change observed in neurogenic shock following spinal cord injury?

Decreased vascular resistance

rationale: Neurogenic shock is characterized by decreased systemic vascular resistance due to the loss of sympathetic tone, leading to widespread vasodilation.

Which of the following is an early manifestation of septic shock?

Tachycardia

rationale: Tachycardia is an early manifestation of septic shock. It is the body's response to the infection and helps maintain cardiac output.

During the assessment of a patient with neurogenic shock, which of the following cues should the nurse recognize as a manifestation of this condition?

Bradycardia

rationale: Neurogenic shock is characterized by bradycardia (decreased heart rate) due to the loss of sympathetic tone.

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Increased heart rate

rationale: The nurse should anticipate an increased heart rate as an early indication of shock because the body attempts to compensate for decreased circulatory volume.

A 60-year-old male patient presents with symptoms of hypotension, tachycardia, cool and clammy skin, and altered mental status following severe blood loss from a traumatic injury. Based on these symptoms, what type of shock is the patient likely experiencing?

Hypovolemic shock

rationale: This response is correct because the symptoms of hypotension, tachycardia, cool and clammy skin, and altered mental status following severe blood loss are indicative of hypovolemic shock.

Which of the following is a nutritional need for a client in shock?

High-protein diet

rationale: A high-protein diet is a nutritional need for a client in shock. Protein is essential for tissue repair and wound healing, which are important in the recovery process.

What is a priority education topic for the family of a patient experiencing Multiple Organ Dysfunction Syndrome (MODS)?

Recognizing signs of organ failure and when to seek urgent care

rationale: Educating the family on recognizing signs of worsening organ failure is crucial in managing MODS effectively, ensuring timely interventions.

Which of the following medications is most commonly used as a first-line treatment for patients experiencing anaphylactic shock?

Epinephrine

rationale: Epinephrine is the first-line treatment for anaphylactic shock due to its ability to quickly counteract the severe allergic reaction by causing vasoconstriction and bronchodilation.

When suspecting cardiogenic shock, the nurse should recognize which clinical cues? (Select all that apply)

- hypotension

- JVD

- tachycardia

A client is admitted to the emergency department with cardiogenic shock. Which of the following interventions should the nurse prioritize?

Initiating intravenous fluid resuscitation

rationale: Intravenous fluid resuscitation is a priority intervention to increase circulating volume and improve cardiac output in clients with cardiogenic shock.

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?

A client who has Guillain-Barré syndrome

rationale: Clients whose autonomic nerves have been affected by Guillain-Barré syndrome are at risk for developing neurogenic shock because both blood pressure and heart rate are controlled by the autonomic nervous system. Clients whose autonomic nerves have been affected by Guillain-Barré syndrome are at risk for developing neurogenic shock because both blood pressure and heart rate are controlled by the autonomic nervous system.

Which of the following is a characteristic of cardiogenic shock in a patient with a myocardial infarction?

a. increased blood pressure

b. normal O2 sat

c. elevated HR

d. decreased cardiac output

Decreased cardiac output

rationale: Cardiogenic shock is characterized by a significant decrease in cardiac output, leading to inadequate tissue perfusion.

A nurse is caring for a client with MODS. Which of the following assessments should the nurse prioritize?

Assessing for changes in mental status

rationale: Assessing for changes in mental status is a priority assessment for a client with MODS. It can indicate neurological involvement and worsening organ dysfunction.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

Packed RBCs

rationale: Packed RBCs are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock.

Which of the following is a characteristic of cardiogenic shock?

Decreased cardiac output

rationale: Cardiogenic shock is characterized by a significant decrease in cardiac output, leading to inadequate tissue perfusion.

A nurse is caring for a client with MODS. Which of the following interventions should the nurse prioritize for the client's respiratory system?

Assessing lung sounds for adventitious lung sounds

rationale: Assessing lung sounds for adventitious sounds is a priority intervention to monitor the client's respiratory status and identify any abnormalities or changes that may require further intervention.

A 65-year-old patient is admitted to the emergency department with symptoms of septic shock. Which of the following actions should the nurse prioritize first?

Initiate intravenous fluid resuscitation

rationale: Immediate fluid resuscitation is the first priority to maintain adequate tissue perfusion and prevent further deterioration.

A patient is exhibiting the following signs: hypotension, tachycardia, altered mental status, and cool clammy skin. Which of the following is a cue indicating the patient is experiencing irreversible shock?

Decreased urine output

rationale: In irreversible shock, the body's compensatory mechanisms have failed and perfusion to vital organs is severely compromised. This can lead to decreased urine output as the kidneys receive less blood flow.

What is the nurse's priority when viewing the lab values for a patient with compensatory shock?

Monitor fluid balance

rationale: Monitoring fluid balance is a priority for a patient with compensatory shock as it helps determine if the patient is hypovolemic or experiencing fluid overload.

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?

Confusion

rationale: Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine

rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine, a bronchodilator and vasopressor used for allergic reactions to reverse severe manifestations of anaphylactic shock.

Which of the following best describes the pathophysiology of neurogenic shock?

Decreased sympathetic outflow leading to vasodilation and decreased vascular resistance

rationale: Neurogenic shock occurs as a result of injury to the spinal cord or brain, leading to decreased sympathetic outflow. This results in widespread vasodilation and decreased vascular resistance, leading to hypotension.

A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching?

"I will use ink pens for writing"

rationale: The client understands pencil erasers contain latex and should use pens for writing instead.

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria

rationale: Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.

Which of the following is a potential complication of anaphylactic shock?

Respiratory distress

rationale: Respiratory distress is a common complication of anaphylactic shock, as it can lead to severe difficulty in breathing.

A patient in progressive shock may exhibit which of the following cues?

Hypotension

rationale: Hypotension is a common cue in progressive shock. As the body goes into shock, blood pressure drops significantly.

When managing medications for a client with multiple organ dysfunction syndrome (MODS), which of the following is an important consideration?

Administering medications that are metabolized primarily by the liver

rationale: In clients with MODS, liver function may be impaired, leading to decreased metabolism of medications. Therefore, it is important to consider administering medications that are metabolized primarily by other organs, such as the kidneys.

A patient presents with warm, flushed skin, decreased blood pressure, rapid weak pulse, and decreased urine output. Which type of shock is the patient most likely experiencing?

Neurogenic shock

rationale: Neurogenic shock occurs as a result of spinal cord injury or dysfunction, leading to widespread vasodilation and decreased cardiac output. Symptoms include hypotension, bradycardia, and warm, dry skin.

Which of the following laboratory findings is most indicative of multi organ dysfunction syndrome (MODS)?

Elevated serum lactate levels

rationale: Elevated serum lactate levels are indicative of tissue hypoxia and anaerobic metabolism, which are common in MODS due to impaired organ perfusion.

Which hypothesis should be prioritized for a client with MODS?

The client's respiratory distress is the primary hypothesis as it directly affects oxygen

rationalr: Respiratory distress is a common symptom of MODS and can quickly lead to hypoxemia and organ failure. Addressing this hypothesis first is crucial for maintaining oxygenation and preventing further complications.

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Increased respiratory rate

rationale: When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.

What is the nurse's priority when viewing lab values for a patient with multi organ dysfunction syndrome?

Monitor renal function

rationale: In multi organ dysfunction syndrome, multiple organ systems are affected, including the kidneys. Monitoring renal function is a priority as impaired kidney function can lead to further complications.

A patient presents with cold, clammy skin, rapid breathing, and confusion. What type of shock is most likely occurring?

Cardiogenic shock

rationale: Cardiogenic shock is characterized by cold, clammy skin, rapid breathing, and confusion. It occurs when the heart is unable to pump enough blood to meet the body's needs.

A client presents with neurogenic shock. Which of the following assessments should the nurse prioritize?

Monitoring for signs of hypotension and decreased perfusion

rationale: In neurogenic shock, there is a loss of sympathetic tone leading to vasodilation and decreased systemic vascular resistance, resulting in hypotension and decreased perfusion. Monitoring for signs of hypotension and decreased perfusion is a priority assessment to evaluate the client's hemodynamic status and guide interventions.

Which of the following is a potential complication of hypovolemic shock?

Acute respiratory distress syndrome (ARDS)

rationale: ARDS can occur as a result of hypovolemic shock due to inadequate tissue perfusion and oxygenation.

What is the nurse's priority when caring for a client with MODS?

Stabilizing the client's airway and breathing

rationale: Stabilizing the client's airway and breathing is the nurse's priority when caring for a client with MODS. As the lungs are commonly the primary organ of dysfunction in MODS, ensuring adequate oxygenation and ventilation is crucial for the client's survival and overall perfusion.

A client with neurogenic shock is prescribed medication to manage their condition. Which of the following medications would be appropriate for the nurse to administer?

- warfarin

- epinephrine

- nitroglycerin

- furosemide

- insulin

- morphine

- metorpolo

- aspirin

- epinephrine

- morphine

rationale: Neurogenic shock is characterized by hypotension and bradycardia. Medications that may be used in the management of neurogenic shock include epinephrine, which increases blood pressure and cardiac output, and morphine, which can help reduce pain and anxiety. Aspirin, metoprolol, furosemide, insulin, nitroglycerin, and warfarin are not typically used in the management of neurogenic shock.

A client presents with signs and symptoms of sepsis. Which intervention should the nurse prioritize?

Administer broad-spectrum antibiotics

rationale: Administering broad-spectrum antibiotics is a priority intervention in sepsis management to target the underlying infection.

Which of the following medications is commonly used in the management of shock?

Norepinephrine

rationale: Norepinephrine is commonly used in the management of shock as a vasopressor medication to increase blood pressure and improve perfusion.

Which of the following is a complication of cardiogenic shock?

a. hyperglycemia

b. pulmonary embolism

c. hypertension

d. arrhythmias

Arrhythmias

rationale: Cardiogenic shock can lead to abnormal heart rhythms, known as arrhythmias.