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

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?

Ten minutes following administration of an antibiotic,the nurse assesses a patient to have edematous lips,hoarseness,and expiratory stridor.Vital signs assessed by the nurse include blood pressure 70/40 mm Hg,heart rate 130 beats/min,and respirations 36 breaths/min.What is the priority intervention?

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 is caring for a 70-kg patient in hypovolemic shock.Upon initial assessment,the nurse notes a blood pressure of 90/50 mm Hg,heart rate 125 beats/min,respirations 32 breaths/min,central venous pressure (CVP/RAP)of 3 mm Hg,and urine output of 5 mL during the past hour.Following physician rounds,the nurse reviews the orders and questions which order?

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 cardiogenic shock experiencing chest pain.Hemodynamic values assessed by the nurse include a cardiac index (CI)of 2.5 L/min/m²,heart rate of 70 beats/min,and a systemic vascular resistance (SVR)of 2200 dynes/sec/cm^-5.Upon review of physician orders,which order is most appropriate for the nurse to initiate?

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?

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC).Which action by the nurse best protects against the development of a central line-associated bloodstream infection (CLABSI)?

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

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 starting to administer a unit of packed red blood cells (PRBCs)to a patient admitted in hypovolemic shock secondary to hemorrhage.Vital signs include blood pressure 60/40 mm Hg,heart rate 150 beats/min,respirations 42 breaths/min,and temperature 100.6° F.What is the best action by the nurse?

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 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 caring for a patient admitted with shock.The nurse understands which assessment findings best assess tissue perfusion in a patient in shock?