Nokea
The nurse is caring for a patient who is receiving vasopressin to treat septic shock. Which of the following assessments is most important for the nurse to communicate to the health care provider?
- A. The patient's heart rate is 108 beats/minute
- B. The patient is complaining of chest pain
- C. The patient's peripheral pulses are weak
- D. The patient's urine output is 15 ml/hour
Correct Answer: B
Rationale: Chest pain in a patient receiving vasopressin, a potent vasoconstrictor, may indicate decreased coronary artery perfusion, requiring immediate reporting to the provider. The other findings are consistent with septic shock but are less urgent than potential cardiac ischemia.
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The nurse is caring for a patient with neurogenic shock who is receiving a phenylephrine infusion through a left forearm IV. Which of the following assessment information obtained by the nurse indicates a need for immediate action?
- A. The patient's IV infusion site is cool and pale
- B. The patient has warm, dry skin on the extremities
- C. The patient has an apical pulse rate of 58 beats/minute
- D. The patient's urine output has been 20 mL over the last hour
Correct Answer: A
Rationale: Coolness and pallor at the IV site suggest extravasation of phenylephrine, a potent vasoconstrictor, which can cause tissue damage and requires immediate action to stop the infusion and notify the provider. The other findings are consistent with neurogenic shock but do not require immediate intervention.
The nurse is caring for a patient with septic shock who has had a urine output of 20 ml/hour for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of the following orders by the health care provider should the nurse question?
- A. Administer furosemide 40 mg IV
- B. Increase normal saline infusion to 150 ml/hour
- C. Administer hydrocortisone 100 mg IV
- D. Administer dopamine 5 mcg/kg/minute IV
Correct Answer: A
Rationale: Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock, who already has low central venous pressure and pulmonary artery wedge pressure, indicating hypovolemia. The other orders are appropriate to improve perfusion and manage septic shock.
Which of the following interventions should the nurse include in the plan of care for a patient experiencing cardiogenic shock?
- A. Avoid elevating head of bed
- B. Check temperature every 2 hours
- C. Monitor breath sounds frequently
- D. Assess skin for flushing and itching
Correct Answer: C
Rationale: Frequent monitoring of breath sounds is critical in cardiogenic shock to detect pulmonary congestion and dyspnea, which are hallmark symptoms. Elevating the head of the bed reduces dyspnea, temperature monitoring is less specific, and flushing or itching is not typical of cardiogenic shock.
The nurse is caring for a patient with shock whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which of the following prescribed interventions should the nurse question?
- A. Infuse normal saline at 250 ml/hour
- B. Keep head of bed elevated to 30 degrees
- C. Give nitroglycerin unless systolic BP <90 mm Hg
- D. Administer dobutamine to keep systolic BP >90 mm Hg
Correct Answer: A
Rationale: The patient's elevated pulmonary artery wedge pressure indicates volume excess, and infusing normal saline at 250 ml/hour could worsen this condition, potentially leading to pulmonary edema. The other actions are appropriate to support cardiac function and manage shock.
The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. Which of the following should the nurse obtain in preparation for the patient's arrival?
- A. 500 mL of 5% albumin
- B. Lactated Ringer's solution
- C. Two 14-gauge IV catheters
- D. Dopamine infusion
Correct Answer: C
Rationale: Two large-bore (14-gauge) IV catheters are essential for rapid fluid resuscitation in a trauma patient to prevent or treat hypovolemic shock. Crystalloids like normal saline are preferred initially over colloids like albumin. Lactated Ringer's should be used cautiously, and vasopressors like dopamine are not first-line for hypovolemic shock.