Nokea
The nurse is caring for a patient with septic shock who has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 40°C, and arterial oxygen saturation of 88%. Which of the following interventions should the nurse implement first?
- A. Administer acetaminophen 650 mg via nasogastric tube
- B. Give drotrecogin-?± IV
- C. Administer oxygen via non-rebreather mask
- D. Infuse normal saline 500 mL over 30 minutes
Correct Answer: C
Rationale: Administering oxygen via a non-rebreather mask is the priority to address the patient's low oxygen saturation (88%) and ensure adequate oxygenation in septic shock. Other interventions, such as fluids, drotrecogin-?±, or acetaminophen, are important but secondary to correcting hypoxemia.
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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.
The new RN is being mentored while caring for a patient with neurogenic shock. Which of the following actions by the new RN indicates a need for further teaching?
- A. Keeping the room temperature at 75°F to prevent hypothermia
- B. Checking the heart rate every 1-2 hours
- C. Preparing to administer prescribed IV atropine
- D. Increasing the nitroprusside infusion rate for a patient with a high SVR
Correct Answer: D
Rationale: Increasing the nitroprusside infusion rate is inappropriate for neurogenic shock, as it is a vasodilator and could worsen hypotension. The other actionsâ??maintaining warm room temperature, monitoring heart rate, and preparing atropineâ??are appropriate for managing neurogenic shock, which involves bradycardia and hypothermia risk.
The nurse is caring for a patient in the emergency department (ED) with massive trauma and possible spinal cord injury. Which of the following findings by the nurse will help confirm a diagnosis of neurogenic shock?
- A. Cool, clammy skin
- B. Inspiratory crackles
- C. Apical heart rate 48 beats/minute
- D. Temperature 38.4°C (101.1°F)
Correct Answer: C
Rationale: Neurogenic shock is characterized by hypotension and bradycardia due to loss of sympathetic tone, as seen with an apical heart rate of 48 beats/minute. Cool, clammy skin is more typical of hypovolemic or cardiogenic shock, inspiratory crackles suggest pulmonary edema, and fever is not specific to neurogenic 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.