Question 1

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?

Accepted Answer

A)  The patient is developing neurogenic shock. 
B)  The patient is experiencing an allergic reaction. 
C)  The patient most likely has an elevated temperature. 
D)  The vital signs are normal for this patient.

Question 2

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.)

Accepted Answer

A)  Blood pressure 
B)  Heart rate 
C)  Level of consciousness 
D)  Pupil response 
E)  Respirations
F) Urine output

Question 3

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?

Accepted Answer

A)  Blood cultures 
B)  Chest x-ray 
C)  Foley insertion 
D)  Serum electrolytes

Question 4

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?

Accepted Answer

A)  Cardiac index (CI) of 2.5 L/min/m² 
B)  Pulmonary artery diastolic pressure of 26 mm Hg 
C)  Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg 
D)  Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5

Question 5

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?

Accepted Answer

A)  Blood pressure 100/60 mm Hg 
B)  Swelling at the IV site 
C)  Heart rate of 110 beats/min 
D)  Central venous pressure ( CVP ) of 8 mm Hg

Question 6

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?

Accepted Answer

A)  Human albumin infusion 
B)  Hypotonic saline solution 
C)  Lactated Ringer's bolus 
D)  Packed red blood cells

Question 7

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?

Accepted Answer

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

Question 8

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?

Accepted Answer

A)  Administer pain medication. 
B)  Turn patient every 2 hours. 
C)  Assess core body temperature. 
D)  Apply bilateral heel protectors.

Question 9

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.)

Accepted Answer

A)  Administer acetaminophen (Tylenol). 
B)  Document the patient's response. 
C)  Increase the rate of transfusion. 
D)  Notify the blood bank. 
E)  Notify the physician.
F) Stop the transfusion.

Question 10

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?

Accepted Answer

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."

Question 11

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?

Accepted Answer

A)  Normal body temperature 
B)  Balanced intake and output 
C)  Adequate pain management 
D)  Urine output of 0.5 mL/kg/hr

Question 12

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?

Accepted Answer

A)  Frequent turning 
B)  Monitoring intake and output 
C)  Enteral feedings 
D)  Pain management

Question 13

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

Accepted Answer

A)  Arterial vasodilation 
B)  High urine output 
C)  Increased parasympathetic stimulation 
D)  Increased sympathetic stimulation

Question 14

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?

Accepted Answer

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.

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