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The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion?
- A. The patient is in the compensatory stage of shock.
- B. The patient is in the progressive stage of shock.
- C. The patient will stabilize and be released by tomorrow.
- D. The patient is in the irreversible stage of shock.
Correct Answer: A
Rationale: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the patients chance of survival is low and he will certainly not be released within 24 hours. If the patient were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.
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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.
A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patients mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply.
- A. Blood urea nitrogen (BUN) level
- B. Urine specific gravity
- C. Alkaline phosphatase level
- D. Creatinine level
- E. Serum albumin level
Correct Answer: A,B,D
Rationale: Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acid-base imbalances, and a loss of the renal-hormonal regulation of BP. Urine specific gravity is also affected. Alkaline phosphatase and albumin levels are related to hepatic function.
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patients infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patients risk of septic shock?
- A. Apply an antibiotic ointment to the patients mucous membranes, as ordered.
- B. Perform passive range-of-motion exercises unless contraindicated
- C. Initiate total parenteral nutrition (TPN)
- D. Remove invasive devices as soon as they are no longer needed
Correct Answer: D
Rationale: Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.
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.
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.