Nokea
The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the patient?
- A. Anaphylaxis
- B. Decreased oxygen consumption
- C. Abdominal compartment syndrome
- D. Decreased serum osmolality
Correct Answer: C
Rationale: Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are administered. The scenario does not describe an antigen-antibody reaction of any type. Decreased oxygen consumption by the body is not a concern in hypovolemic shock. With a decrease in fluids in the intravascular space, increased serum osmolality would occur.
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A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boys mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock?
- A. Rapid onset of acute hypertension
- B. Rapid onset of respiratory distress
- C. Rapid onset of neurologic compensation
- D. Rapid onset of cardiac arrest
Correct Answer: B
Rationale: Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur if prompt treatment is not provided.
The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient?
- A. It promotes coping and slows catecholamine release.
- B. It stimulates the patient so he or she is more alert.
- C. It decreases gastric secretions.
- D. It dilates the blood vessels.
Correct Answer: D
Rationale: For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patients anxiety. Morphine would not be ordered to promote coping or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions.
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.
The nurse is caring for a patient whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock?
- A. Elevated systolic blood pressure
- B. Elevated mean arterial pressure (MAP)
- C. Shallow, rapid respirations
- D. Bradycardia
Correct Answer: C
Rationale: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.
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.