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

The nurse is caring for an 18-year-old 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?

The nurse is caring for a young adult patient admitted with shock.The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.)

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

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?

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?

The nurse is caring for a patient admitted following a motor vehicle crash.Over the past 2 hours,the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion.To prevent complications,what is the priority nursing intervention?

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 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 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 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?

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

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?