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After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. Which of the following prescribed medications should the nurse administer?
- A. Nitroglycerin
- B. Drotrecogin-?±
- C. Norepinephrine
- D. Sodium nitroprusside
Correct Answer: C
Rationale: Norepinephrine, a vasopressor, is appropriate to increase systemic vascular resistance and improve blood pressure when fluid resuscitation is insufficient in septic shock. Nitroglycerin and nitroprusside are vasodilators and would worsen hypotension, while drotrecogin-?± addresses inflammation but not blood pressure directly.
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During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which of the following findings is most important for the nurse to report to the health care provider?
- A. Decreased bowel sounds
- B. Apical pulse 110 beats/minute
- C. Pale, cool, and dry extremities
- D. New onset of confusion and agitation
Correct Answer: D
Rationale: New onset confusion and agitation indicate progression to the progressive stage of hypovolemic shock, signaling inadequate cerebral perfusion and the need for immediate intervention. The other findings are consistent with compensatory shock but are less urgent.
Which of the following interventions should the nurse include in the plan of care for a patient experiencing cardiogenic shock?
- A. Avoid elevating head of bed
- B. Check temperature every 2 hours
- C. Monitor breath sounds frequently
- D. Assess skin for flushing and itching
Correct Answer: C
Rationale: Frequent monitoring of breath sounds is critical in cardiogenic shock to detect pulmonary congestion and dyspnea, which are hallmark symptoms. Elevating the head of the bed reduces dyspnea, temperature monitoring is less specific, and flushing or itching is not typical of cardiogenic shock.
The health care provider prescribes the following actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions?
- A. Obtain blood and urine cultures
- B. Give vancomycin 1 g IV
- C. Infuse vasopressin 0.01 units/minute
- D. Administer normal saline 1000 mL over 30 minutes
- E. Titrate oxygen administration to keep O2 saturation >95%
Correct Answer: E,D,C,A,B
Rationale: The priority is to improve oxygenation (titrate oxygen), followed by fluid resuscitation (normal saline), vasopressor administration (vasopressin), obtaining cultures, and finally administering antibiotics (vancomycin) to ensure timely treatment while confirming the infection source.
The nurse is caring for a patient with neurogenic shock that has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take? (Select all that apply.)
- A. Prepare to administer atropine IV
- B. Obtain baseline body temperature
- C. Prepare for intubation and mechanical ventilation
- D. Administer large volumes of lactated Ringer's solution
- E. Administer high-flow oxygen (100%) by non-rebreather mask
Correct Answer: A,B,C,E
Rationale: Neurogenic shock requires atropine for bradycardia, temperature monitoring for poikilothermia, preparation for intubation due to potential respiratory compromise, and high-flow oxygen to support oxygenation. Large volumes of lactated Ringer's are avoided to prevent volume overload, as blood volume is typically normal in neurogenic shock.
The nurse is caring for a patient who has septic shock. Which of the following assessment findings is most important for the nurse to report to the health care provider?
- A. BP 92/56 mm Hg
- B. Skin cool and clammy
- C. Apical pulse 118 beats/minute
- D. Arterial oxygen saturation 91%
Correct Answer: B
Rationale: Cool, clammy skin in septic shock indicates progression from the early warm, flushed stage to a more severe stage with poor perfusion, requiring urgent intervention. The other findings are consistent with septic shock but do not indicate deterioration as critically as cool, clammy skin.