Exam 11: Shock, sepsis, and Multiple Organ Dysfunction Syndrome

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 )2 mm Hg,and urine output of 10 mL for the past hour.The nurse initiates which active physician order first?

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer 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 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 caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter ( CVC ).What action by the nurse best protects against the development of a central line-associated bloodstream infection ( CLABSI )?

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?

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?

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?

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 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 administration of a 1000-L bolus of 0.9% normal saline.The nurse assesses the patient to be slightly confused,with a mean arterial blood pressure (MAP)of 50 mm Hg,a heart rate of 110 beats/min,urine output of 10 mL for the past hour,and a central venous pressure (CVP/RAP)of 3 mm Hg.What is the best interpretation of these results by the nurse?

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?

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 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?

While monitoring a patient for signs of shock,the nurse understands which system assessment to be of priority?

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?

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.Assuming physician orders,which intervention should the nurse carry out first?

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 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 96.8° F.Which intervention is most important for the nurse to include in the patient's plan of care?

The nurse is caring for a patient in cardiogenic shock who is 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?