Nokea
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patients plan of care while the patient is ventilated?
- A. Performing frequent oral care
- B. Maintaining the patient in a supine position
- C. Suctioning the patient every 15 minutes unless contraindicated
- D. Administering prophylactic antibiotics, as ordered
Correct Answer: A
Rationale: Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.
You may also like to solve these questions
The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications?
- A. Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration
- B. Reviewing medications, performing a focused cardiovascular assessment, and providing patient education
- C. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema
- D. Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions
Correct Answer: A
Rationale: When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the patients response. Reviewing medications, performing a focused cardiovascular assessment, and providing patient education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema are not the priorities for administration of IV vasoactive drugs. Vital signs are taken on a frequent basis when monitoring administration of IV vasoactive drugs, vasoactive medications should be administered through a central venous line, and early discharge instructions would be inappropriate in this time of crisis.
The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
- A. Increased urine output
- B. Decreased heart rate
- C. Hyperactive bowel sounds
- D. Cool, clammy skin
Correct Answer: D
Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patients skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.
A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply.
- A. Anaphylactic
- B. Hypovolemic
- C. Cardiogenic
- D. Septic
- E. Neurogenic
Correct Answer: A,D,E
Rationale: The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of circulatory shock.
You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient?
- A. Hypothermia
- B. Bradycardia
- C. Coffee ground emesis
- D. Pain
Correct Answer: A
Rationale: Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the patient for cardiovascular overload and pulmonary edema when large volumes of IV solution are administered. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock.
The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply.
- A. Drop in systolic blood pressure of 40 mm Hg from baselines
- B. Hypotension that responds to bolus fluid resuscitation
- C. Exaggerated response to vasoactive medications
- D. Serum lactate >4 mmol/L
- E. Mean arterial pressure (MAP) of 65 mm Hg
Correct Answer: A,D,E
Rationale: Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg, mean arterial pressure (MAP) <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines, or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted.