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An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a really bad allergic reaction to peanuts after trading lunches with a peer. The triage nurses rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize?
- A. Establishing central venous access and beginning fluid resuscitation
- B. Establishing a patent airway and beginning cardiopulmonary resuscitation
- C. Establishing peripheral IV access and administering IV epinephrine
- D. Performing a comprehensive assessment and initiating rapid fluid replacement
Correct Answer: B
Rationale: If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. As well, a patent airway is an immediate priority. Epinephrine is not withheld pending IV access and fluid resuscitation is not a priority.
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The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on what intervention?
- A. Reviewing the cause of shock and prioritizing the patients psychosocial needs
- B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
- C. Giving the prescribed treatment, but shifting focus to providing family time as the patient is unlikely to survive
- D. Promoting the patients coping skills in an effort to better deal with the physiologic changes accompanying shock
Correct Answer: B
Rationale: Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.
A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurses care planning during the administration of a vasoactive drug?
- A. The drug should be discontinued immediately after blood pressure increases.
- B. The drug dose should be tapered down once vital signs improve.
- C. The patient should have arterial blood gases drawn every 10 minutes during treatment.
- D. The infusion rate should be titrated according the patients subjective sensation of adequate perfusion.
Correct Answer: B
Rationale: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but every 10-minute draws are not the norm.
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.
An adult patient has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this patient. What aspect of his care should be prioritized by the home health nurse?
- A. Providing supervision to home health aides in providing necessary patient care
- B. Assisting the patient and family to identify and mobilize community resources
- C. Providing ongoing medical care during the familys rehabilitation phase
- D. Reinforcing the importance of continuous assessment with the family
Correct Answer: B
Rationale: The home care nurse reinforces the importance of continuing medical care and helps the patient and family identify and mobilize community resources. The home health nurse is part of a team that provides patient care in the home. The nurse does not directly supervise home health aides. The nurse provides nursing care to both the patient and family, not just the family. The nurse performs continuous and ongoing assessment of the patient; he or she does not just reinforce the importance of that assessment.
A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patients care?
- A. Communicate clearly and frequently with the patients family.
- B. Taper down interventions slowly when the prognosis worsens.
- C. Transfer the patient to a subacute unit when recovery appears unlikely.
- D. Ask the patients family how they would prefer treatment to proceed.
Correct Answer: A
Rationale: As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the patients care, for the family to see, touch, and talk to the patient. The onus should not be placed on the family to guide care, however. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The patient would not be transferred to a subacute unit.