Nokea
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.
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During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which of the following findings is most important for the nurse to report to the health care provider?
- A. Decreased bowel sounds
- B. Apical pulse 110 beats/minute
- C. Pale, cool, and dry extremities
- D. New onset of confusion and agitation
Correct Answer: D
Rationale: New onset confusion and agitation indicate progression to the progressive stage of hypovolemic shock, signaling inadequate cerebral perfusion and the need for immediate intervention. The other findings are consistent with compensatory shock but are less urgent.
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 in noncardiogenic shock who is cool, clammy and whose hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which of the following actions should the nurse anticipate implementing?
- A. Increase the rate for the prescribed dopamine infusion
- B. Decrease the rate for the prescribed nitroglycerin infusion
- C. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion
- D. Increase the rate for the prescribed sodium nitroprusside infusion
Correct Answer: D
Rationale: Nitroprusside is an arterial vasodilator that will decrease the high SVR and afterload, improving cardiac output in noncardiogenic shock. Increasing dopamine would increase SVR, nitroglycerin primarily affects preload, and D5W does not directly address SVR.
Which of the following assessments is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective?
- A. Pulse rate
- B. Orientation
- C. Blood pressure
- D. Oxygen saturation
Correct Answer: D
Rationale: Oxygen saturation is the most critical assessment in anaphylactic shock due to the risk of airway edema affecting breathing. Improvements in pulse rate, orientation, and blood pressure are expected but are secondary to ensuring adequate oxygenation.
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.