The document discusses signs and symptoms that indicate different types of shock, risk factors for sepsis, appropriate nursing interventions for patients in shock, and indicators of effective therapy. It provides scenarios about postoperative or trauma patients in hypovolemic or neurogenic shock and questions about the best nursing actions. Recognizing early signs of different types of shock and providing appropriate treatment are essential skills for nurses.
The document discusses signs and symptoms that indicate different types of shock, risk factors for sepsis, appropriate nursing interventions for patients in shock, and indicators of effective therapy. It provides scenarios about postoperative or trauma patients in hypovolemic or neurogenic shock and questions about the best nursing actions. Recognizing early signs of different types of shock and providing appropriate treatment are essential skills for nurses.
The document discusses signs and symptoms that indicate different types of shock, risk factors for sepsis, appropriate nursing interventions for patients in shock, and indicators of effective therapy. It provides scenarios about postoperative or trauma patients in hypovolemic or neurogenic shock and questions about the best nursing actions. Recognizing early signs of different types of shock and providing appropriate treatment are essential skills for nurses.
The document discusses signs and symptoms that indicate different types of shock, risk factors for sepsis, appropriate nursing interventions for patients in shock, and indicators of effective therapy. It provides scenarios about postoperative or trauma patients in hypovolemic or neurogenic shock and questions about the best nursing actions. Recognizing early signs of different types of shock and providing appropriate treatment are essential skills for nurses.
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1. In a client with hypovolemic shock what indicates that the therapy is effective?
A. Urine output increase from 5 mL/hr to 30 mL/hr
B. Pulse pressure decrease from 35 mmHg to 28 mmHg C. Respiratory rate increase from 22 breaths/min to 26 breaths/min D. Core body temperature increase from 36.8 C to 38.5 C
2. Which of the following patient considers to be at highest risk for development of
sepsis? A. 75-year-old man with hypertension B. 68-year-old woman 2 days postoperative from bowel surgery C. 80-year-old man with no other health problems undergoing cataract surgery D. 54-year-old woman with moderate asthma and severe degenerative joint disease
3. A septic shock patient has a urine output of 20 mL/hr for the past 4 hours. The pulse rate is 120 and the central venous pressure is low. Which of the following physician’s order will the nurse question? a. Give furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c. Administer hydrocortisone 100 mg IV. d. Prepare to give atropine sulfate 1mg IV.
4. 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.
. 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)
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which of the following would cause the nurse to suspect that the client has early shock?
A. Hypotension B. Bradypnea C. Irregular heart rhythm D. Tachycardia
When caring for an obtunded ED client with shock of unknown origin, which action should the nurse take first? A. Establish IV access and hang prescribed infusion B. Apply the automatic BP cuff C. Assess level of consciousness and pupil response to light D. Check the airway and respiratory status
A postoperative client is admitted to the ICU with hypovolemic shock. Which nursing action should the nurse delegate to the experienced nursing assistant?
A. Obtain vital signs every 15 minutes
B. Measure hourly urine output C. Check oxygen saturation D. Assess level of alertness
The nursing assistant reports concerns about the postoperative client who has BP 90/60, HR 80, R 22. What should the RN do?
A. Compare these VS with last several readings
B. Request that the surgeon come see the client C. Increase the rate of IV fluids D. Reassess VS using different equipment
Which of the following would indicate a positive outcome after starting dopamine (Intropin)?
A. Hourly urine output of 10-18 mL
B. BP 90/60 and MAP 70 C. Blood glucose 245 D. Serum creatinine 3.6mg/dL
How does the nurse recognize that the client is in early stages of septic shock?
A. Pallor and cool skin
B. Blood pressure 84/50 C. Tachypnea & tachycardia D. Respiratory acidosis
