Exam 12: Shock,Sepsis,and Multiple Organ Dysfunction Syndrome

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock,the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg,heart rate 135 beats/min,respirations 40 breaths/min,and a temperature of 102° F.The nurse notes the new onset of hematuria in the patient's Foley catheter.What are the priority nursing actions? (Select all that apply.)

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer's solution over the past 4 hours.Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%.What is the best interpretation of these findings by the nurse?

The nurse is administering intravenous norepinephrine at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV)catheter.Which assessment finding requires immediate action by the nurse?

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP)for cardiogenic shock unresponsive to pharmacotherapy.Which hemodynamic parameter best indicates an appropriate response to therapy?

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis.What findings assessed by the nurse indicate an appropriate response to therapy?

The emergency department nurse admits a patient following a motor vehicle collision.Vital signs include blood pressure 70/50 mm Hg,heart rate 140 beats/min,respiratory rate 36 breaths/min,temperature 101° F and oxygen saturation (SpO₂)95% on 3 L of oxygen per nasal cannula.Laboratory results include hemoglobin 6.0 g/dL,hematocrit 20%,and potassium 4.0 mEq/L.Based on this assessment,what is most important for the nurse to include in the patient's plan of care?

The nurse is caring for a patient admitted with cardiogenic shock.Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP)of 18 mm Hg and a cardiac index (CI)of 1.0 L/min/m².What is the priority pharmacological intervention?

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis.As part of this patient's care plan,what intervention is most important for the nurse to discuss with the multidisciplinary care team?

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction.The nurse assesses the patient to be diaphoretic and tachypneic,with bilateral crackles throughout both lung fields.Following insertion of a pulmonary artery catheter by the physician,which hemodynamic values is the nurse most likely to assess?

After receiving a handoff report from the night shift,the nurse completes the morning assessment of a patient with severe sepsis.Vital signs are: 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 )2 mm Hg,and urine output of 10 mL for the past hour.The nurse initiates which provider prescription first?

The nurse is caring for a patient in cardiogenic shock being treated with an intraaortic balloon pump (IABP).The family inquires about the primary reason for the device.What is the best statement by the nurse to explain the IABP?

The nurse is caring for a patient admitted with the early stages of septic shock.The nurse assesses the patient to be tachypneic,with a respiratory rate of 32 breaths/min.Arterial blood gas values assessed on admission are pH 7.50,CO₂ 28 mm Hg,HCO₃ 26.Which diagnostic study result reviewed by the nurse indicates progression of the shock state?

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 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr.What is the best interpretation by the nurse?

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 1 mm Hg.Which intervention should the nurse carry out first?

The nurse is caring for a patient in septic shock.The nurse assesses the patient to have a blood pressure of 105/60 mm Hg,heart rate 110 beats/min,respiratory rate 32 breaths/min,oxygen saturation (SpO₂)95% on 45% supplemental oxygen via Venturi mask,and a temperature of 102° F.The physician orders stat administration of an antibiotic.Which additional physician order should the nurse complete first?

The nurse has been administering 0.9% normal saline intravenous fluids 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?

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?

The nurse is caring for a patient in spinal shock.Vital signs include blood pressure 100/70 mm Hg,heart rate 70 beats/min,respirations 24 breaths/min,oxygen saturation 95% on room air,and an oral temperature of 94.8° F.Which intervention is most important for the nurse to include in the patient's plan of care?

During the initial stages of shock,what are the physiological effects of decreased cardiac output?

The nurse is caring for an athlete with a possible cervical spine (C5)injury following a diving accident.The nurse assesses a blood pressure of 70/50 mm Hg,heart rate 45 beats/min,and respirations 26 breaths/min.The patient's skin is warm and flushed.What is the best interpretation of these findings by the nurse?