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The nurse is caring for a patient in pulmonary edema as result of cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Which of the following actions should the nurse anticipate implementing?
- A. Infusion of 5% human albumin
- B. Administration of furosemide IV
- C. Titration of an epinephrine drip
- D. Administration of hydrocortisone
Correct Answer: B
Rationale: Furosemide, a diuretic, is appropriate to reduce fluid overload in pulmonary edema due to cardiogenic shock, helping to alleviate symptoms like dyspnea. Albumin and normal saline would worsen fluid overload, epinephrine would increase myocardial oxygen demand, and hydrocortisone is used for septic or anaphylactic shock, not cardiogenic shock.
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The nurse is caring for a patient with neurogenic shock that has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take? (Select all that apply.)
- A. Prepare to administer atropine IV
- B. Obtain baseline body temperature
- C. Prepare for intubation and mechanical ventilation
- D. Administer large volumes of lactated Ringer's solution
- E. Administer high-flow oxygen (100%) by non-rebreather mask
Correct Answer: A,B,C,E
Rationale: Neurogenic shock requires atropine for bradycardia, temperature monitoring for poikilothermia, preparation for intubation due to potential respiratory compromise, and high-flow oxygen to support oxygenation. Large volumes of lactated Ringer's are avoided to prevent volume overload, as blood volume is typically normal in neurogenic shock.
The nurse is caring for a patient who has septic shock. Which of the following assessment findings is most important for the nurse to report to the health care provider?
- A. BP 92/56 mm Hg
- B. Skin cool and clammy
- C. Apical pulse 118 beats/minute
- D. Arterial oxygen saturation 91%
Correct Answer: B
Rationale: Cool, clammy skin in septic shock indicates progression from the early warm, flushed stage to a more severe stage with poor perfusion, requiring urgent intervention. The other findings are consistent with septic shock but do not indicate deterioration as critically as cool, clammy skin.
Which of the following information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)?
- A. The patient's serum creatinine level is elevated
- B. The patient complains of intermittent chest pressure
- C. The patient has crackles throughout both lung fields
- D. The patient's extremities are cool and pulses are weak
Correct Answer: A
Rationale: An elevated serum creatinine level indicates renal failure, a sign of MODS in the context of cardiogenic shock. Crackles, chest pressure, and cool extremities are consistent with cardiogenic shock but do not specifically indicate MODS.
Which of the following findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful?
- A. Hemoglobin is within normal limits
- B. Urine output is 60 mL over the last hour
- C. Pulmonary artery occlusive pressure (PAOP) is normal
- D. Mean arterial pressure (MAP) is 65 mm Hg
Correct Answer: B
Rationale: Adequate urine output (e.g., 60 mL/hour) is the best indicator of successful fluid resuscitation in hypovolemic shock, as it reflects restored renal perfusion and end-organ function. Hemoglobin, PAOP, and MAP are useful but less specific for confirming adequate organ perfusion.
The nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which of the following findings indicates that the medication is effective?
- A. No heart murmur is audible
- B. Skin is warm and dry
- C. Troponin level is decreased
- D. Blood pressure is 90/40 mm Hg
Correct Answer: B
Rationale: Warm, dry skin indicates improved tissue perfusion, a sign that nitroprusside, a vasodilator, is effective in reducing afterload and improving cardiac output in cardiogenic shock. Low blood pressure, absence of a heart murmur, or decreased troponin levels are not specific indicators of nitroprusside's effectiveness.