Test bank for introduction to critical care nursing 6th edition by sole download

Test Bank for Introduction to Critical Care Nursing 6th Edition by Sole Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Test Bank MULTIPLE CHOICE The nurse is caring for a patient admitted with hypovolemic shock The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure What is the best nursing action? a Assess the blood pressure by Doppler b Estimate the systolic pressure as 60 mm Hg c Obtain an electronic blood pressure monitor d Record the blood pressure as “not assessable.” ANS: A Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg This action has the potential to delay further assessment of a compromised patient in shock Documenting a blood pressure as not assessable is not appropriate without further attempts using different modalities DIF: Cognitive Level: Application REF: p 258 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis One hour later, which laboratory result requires immediate nursing action? a Creatinine 1.0 mg/dL b Lactate mmol/L c Potassium 3.8 mEq/L d Sodium 140 mEq/L ANS: B Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor All other listed values are within normal limits and not require additional follow-up DIF: Cognitive Level: Application REF: p 259 | Laboratory Alert OBJ: Relate assessment findings to the classification and stage of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a Breath sounds and capillary refill b Blood pressure and oral temperature c Oral temperature and capillary refill d Right atrial pressure and urine output ANS: D Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at mm Hg or greater Combined with urine output, fluid therapy effectiveness can be adequately assessed Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy Capillary refill provides a quick assessment of the patient’s overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock Capillary refill provides a quick assessment of the patient’s overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems DIF: Cognitive Level: Application REF: p 282 OBJ: Describe management strategies for each classification of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies A patient is admitted to the critical care unit following coronary artery bypass surgery Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is mm Hg; cardiac output is L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr What is the best interpretation by the nurse? a The assessed values are within normal limits b The patient is at risk for developing cardiogenic shock c The patient is at risk for developing fluid volume overload d The patient is at risk for developing hypovolemic shock ANS: D Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia Both urine output and chest drainage values are high, contributing to the hypovolemia Assessed values are not within normal limits A cardiac output of L/min is not indicative of cardiogenic shock The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output DIF: Cognitive Level: Analysis REF: p 270 | Table 11-5 OBJ: Relate assessment findings to the classification and stage of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk A patient is admitted after collapsing at the end of a summer marathon She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg The nurse anticipates administering which therapeutic intervention? a Human albumin infusion b Hypotonic saline solution c Lactated Ringer’s bolus d Packed red blood cells ANS: C The patient is experiencing symptoms of hypovolemic shock Isotonic crystalloids, such as normal saline and lactated Ringer’s solutions, are the priority intervention Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation There is no evidence to support a transfusion in the given scenario DIF: Cognitive Level: Analysis REF: p 270 | Table 11-5 OBJ: Describe management strategies for each classification of shock TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies The nurse is caring for a patient in the early stages of septic shock The patient is slightly confused and flushed, with bounding peripheral pulses Which hemodynamic values is the nurse most likely to assess? a High pulmonary artery occlusive pressure and high cardiac output b High systemic vascular resistance and low cardiac output c Low pulmonary artery occlusive pressure and low cardiac output d Low systemic vascular resistance and high cardiac output ANS: D As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance In septic shock, pulmonary artery occlusion pressure is not elevated In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high In the early stages of septic shock, cardiac output is high DIF: Cognitive Level: Knowledge REF: p 270 | Table 11-5 OBJ: Relate assessment findings to the classification and stage of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation The nurse is caring for a patient admitted with severe sepsis Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of mm Hg Assuming physician orders, which intervention should the nurse carry out first? a Acetaminophen suppository b Blood cultures from two sites c IV antibiotic administration d Isotonic fluid challenge ANS: D Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min Fluid resuscitation to restore peotor vehicle crash Over the past hours, the patient has received units of packed red blood cells and units of fresh frozen plasma by rapid infusion To prevent complications, what is the priority nursing intervention? a Administer pain medication b Turn patient every hours c Assess core body temperature d Apply bilateral heel protectors ANS: C Hypothermia is anticipated during the rapid infusion of fluids or blood products Assessment of core body temperature is a priority While administration of pain management, repositioning the patient every hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario DIF: Cognitive Level: Application REF: pp 267-268 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 30 The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex) The physician’s order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2 The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2 What is the best action by the nurse? a Obtain a stat serum potassium level b Order a stat 12-lead electrocardiogram c Reduce the rate of dobutamine (Dobutrex) d Assess the patient’s hourly urine output ANS: C Dobutamine (Dobutrex) is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states improving overall cardiac performance The patient’s cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram Assessment of hourly urine output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario DIF: Cognitive Level: Analysis REF: p 265 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 31 After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) mm Hg, and urine output of 10 mL for the past hour The nurse initiates which active physician order first? a Administer infusion of 500 mL 0.9% normal saline every hours as needed if the CVP is < mm Hg b Increase supplemental oxygen therapy to maintain SpO2greater than 94% c Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr d Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101° F ANS: A