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In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances?
- A. Fluid volume circulating in the blood vessels decreases.
- B. There is an uncontrolled increase in cardiac output.
- C. Blood pressure regulation becomes irregular.
- D. The patient experiences tachycardia and a bounding pulse.
Correct Answer: A
Rationale: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.
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Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression. As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring?
- A. Urinary output increases
- B. Skin becomes warm and dry
- C. Adventitious lung sounds occur in the upper airway
- D. Heart and respiratory rates are elevated
Correct Answer: D
Rationale: As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the patient begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., renal failure, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.
In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the bodys needs?
- A. It slows the proliferation of bacteria and viruses during shock.
- B. It decreases the energy expended through the functioning of the GI system.
- C. It assists in expanding the intravascular volume of the body.
- D. It promotes GI function through direct exposure to nutrients.
Correct Answer: D
Rationale: Parenteral or enteral nutritional support should be initiated as soon as possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feeding. Enteral feeding does not decrease the proliferation of microorganisms or the amount of energy expended through the functioning of the GI system and it does not assist in expanding the intravascular volume of the body.
When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the pooling of blood in the periphery leads to what pathophysiological effect?
- A. Increased stroke volume
- B. Increased cardiac output
- C. Decreased heart rate
- D. Decreased venous return
Correct Answer: D
Rationale: Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.
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.
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.