Nokea
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.
You may also like to solve these questions
The health care provider prescribes the following actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions?
- A. Obtain blood and urine cultures
- B. Give vancomycin 1 g IV
- C. Infuse vasopressin 0.01 units/minute
- D. Administer normal saline 1000 mL over 30 minutes
- E. Titrate oxygen administration to keep O2 saturation >95%
Correct Answer: E,D,C,A,B
Rationale: The priority is to improve oxygenation (titrate oxygen), followed by fluid resuscitation (normal saline), vasopressor administration (vasopressin), obtaining cultures, and finally administering antibiotics (vancomycin) to ensure timely treatment while confirming the infection source.
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 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.
Which of the following assessments should the nurse make to evaluate the effectiveness of omeprazole administration to a patient with systemic inflammatory response syndrome (SIRS)?
- A. Auscultate bowel sounds
- B. Ask the patient about nausea
- C. Monitor stools for occult blood
- D. Check for abdominal distention
Correct Answer: C
Rationale: Omeprazole, a proton pump inhibitor, is given to reduce the risk of stress ulcers in critically ill patients with SIRS. Monitoring stools for occult blood directly assesses the effectiveness of this intervention by checking for gastrointestinal bleeding. The other assessments are relevant but do not specifically evaluate omeprazole's effectiveness.
Which of the following interventions should the nurse implement first when a patient in the emergency department develops anaphylactic shock?
- A. Administer normal saline 500 mL IV
- B. Insert a second IV catheter
- C. Administer epinephrine 0.3 mg intramuscularly
- D. Start a dopamine infusion at 5 mcg/kg/minute
Correct Answer: C
Rationale: Epinephrine is the first-line treatment for anaphylactic shock, as it rapidly reverses vasodilation, bronchoconstriction, and histamine effects. Fluid resuscitation, additional IV access, and vasopressors like dopamine are secondary actions after epinephrine administration.