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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.
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The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patients nutritional needs. What physiologic process contributes to these increased nutritional needs?
- A. The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate (ATP)
- B. The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity
- C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements
- D. The increase in GI peristalsis during shock and the resulting diarrhea
Correct Answer: C
Rationale: Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during 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.
The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way?
- A. Through a central venous line
- B. By a gravity infusion IV set
- C. By IV push for rapid onset of action
- D. Mixed with parenteral feedings to balance osmosis
Correct Answer: A
Rationale: Whenever possible, 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 or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition.
The ICU nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) due to shock. What nursing action should be prioritized at this point during care?
- A. Providing information and support to family members
- B. Preparing the family for a long recovery process
- C. Educating the patient regarding the use of supportive fluids
- D. Facilitating the rehabilitation phase of treatment
Correct Answer: A
Rationale: Providing information and support to family members is a critical role of the nurse. Most patients with MODS do not recover, so the rehabilitation phase of recovery is not a short-term priority. Educating the patient about the use of supportive fluids is not a high priority.
A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patients health problem?
- A. Blood is shunted from vital organs to peripheral areas of the body.
- B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
- C. Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient.
- D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
Correct Answer: B
Rationale: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.