Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
shock.
shock and sepsis
| Question | Answer |
|---|---|
| The nurse is caring for postoperative clients at risk for hypovolemic shock. Which of these represents early symptoms of shock? A) Hypotension B) Bradypnea C) Heart blocks D) Tachycardia | Tachycardia: Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. |
| Which of these problems in the clients below best demonstrates highest risk for hypovolemic shock? A) Client receiving a blood transfusion B) Client with severe ascites C) Client with myocardial infarction D) Client with SIADH | Client with severe ascites Correct: Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion. |
| caring for a client in the refractory stage of cardiogenic shock. Which intervention should the nurse consider? A) Admit to rehab for ambulatory retraining B) Collaborate w/ home care for return home C) Discussion with family regarding palliative care | C. In this irreversible phase, therapy is not effective in saving the client's life, even if the cause of shock is corrected and mean arterial pressure (MAP) temporarily returns to normal. A discussion on palliative care should be considered. |
| A client with septic shock has been started on dopamine at 12 mcg/kg/min. Which response indicates a positive outcome? A) Hourly urine output 10 to 12 mL/hr B) Blood pressure 90/60 and(MAP) 70 C) Blood glucose 245 D) Serum creatinine 3.6 mg/dL | B. Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure-a positive response. |
| The nurse recognizes that the client with which problem is at highest risk for hypovolemic shock? A) Esophageal varices B) Kidney failure C) Arthritis and daily acetaminophen use D) Kidney stone | A. Esophageal varices are caused by portal hypertension; the portal vessels are under high pressure and are prone to rupture, causing massive upper GI bleeding and hypovolemic shock. |
| 7. When analyzing the client's assessment data, the nurse recognizes that which client is at risk for hemorrhagic shock? A) International normalized ratio (INR) 7.9 B) Partial thromboplastin time (PTT) 12.5 C) Platelets 170,000 D) Hemoglobin 8.2 g | A. Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. |
| How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? A) Urine output 20 to 30 mL/hr for the last 4 hours B) Mean arterial pressure 70 C) Albumin level 3.5 D) Hemoglobin 7.6 | B. Plasmanate expands the blood volume and helps maintain MAP greater than 65, which is a desired outcome in shock. |
| How does the nurse recognize that the client is in the early stage of septic shock? A) Pallor and cool skin B) Blood pressure 84/50 C) Tachypnea and tachycardia D) Respiratory acidosis | C. Signs of systemic inflammatory response syndrome, which precede sepsis, include rapid respiratory rate, leukocytosis, and tachycardia,. |
| Which problem places a person at highest risk for septic shock? A) Kidney failure B) Cirrhosis C) Lung cancer D) 40% burn injury | D. The skin forms the first barrier to prevent entry of organisms into the body; this client is at very high risk for sepsis and death |
| The nurse is caring for a group of clients at risk for sepsis. Which problem places the client at highest risk? A) Pernicious anemia B) Pericarditis C) Post-kidney transplant D) Client owns an iguana | C. This client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. |
| How does the nurse caring for the client with septic shock recognize that severe tissue hypoxia is present? A) PaCO2 58 mm Hg B) Lactate level 9.0 mmol/L C) Partial thromboplastin time (PTT) 64 seconds D) Potassium 2.8 mEq/L | B. Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid production. |
| NA is concerned about the postop client BP 90/60, HE 80, RR 22. What should the supervising nurse do? A) Compare these vital signs with the last several readings B) Request the surgeon to see the client C) Increase the rate of IV D) Reassess vital sig | A. Vital sign trends must be taken into consideration; BP of 90/60 may be normal for this client. |
| discharge teaching, Which statement indicates further edu? A)I must call my dr if I develop a fever. B)I will call the dr if I have any pain. C)If the incision site begins to bleed, I will call the dr D)If the site becomes red/ swollen, I will call | B. Some pain is normal for the postoperative client. |
| The client S/S of early shock. What is important for the nurse to do to support the psychosocial integrity of pt? A)Ask family to stay B)Call dr. C)Inc IV and o2 rates. D)Remain with the client. E)Reassure that everything is being done for him or her | A,D, E |
| Which laboratory result is most indicative of effective therapy for sepsis? A) Decreased hemoglobin B) Decreased segmented neutrophil count C) Increased numbers of monocytes D) Increased platelet count | B. A decreased segmented neutrophil count, indicates sepsis is resolving. |
| client admit with to of the (SIRS) variables: temp95° F (35° C)high white blood cell count. Which intervention from the sepsis resuscitation bundle should be initiated? A) Broad-spectrum antibiotics B) Blood transfusion C) Cooling baths D) NPO status | A. Broad-spectrum antibiotics must be initiated within 1 to 3 hours. |
| The nurse plans to adm an antibiotic to the client newly admitted with septic shock. What action should she take? A) Admin the antibiotic immediately. B) Ensure that blood cultures were drawn. C) Obtain signature for informed consent. D) Take vital si | B. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. |
| When caring for a client with hypovolemic shock, the nurse should question which order? A) Dopamine (Intropin) 12 mcg/kg/min B) Dobutamine (Dobutrex) 5 mcg/kg/min C) Plasmanate 1 unit D) Bumetamide (Bumex) 1 mg IV | D. diuretic will decrease blood volume in a client who is already hypovolemic; question this order. This is not an appropriate action to expand the client's blood volume |
| Which nurse should be assigned to care for an intubated client who has septic shock A)LPN w/ 20 years of experience B)The new RN who finished orienting C)The RN who will also be caring for a client who had(CABG) 12 hours ago D)RN w/ 2 years in ICU | D. The RN with current intensive care experience who is not caring for a postoperative client would be an appropriate assignment. |
| A postopis admitted ICU hypovolemic shock. Which action should the nurse delegate to an experienced nursing assistant? A) Obtain vital signs every 15 minutes. B) Measure hourly urine output. C) Check oxygen saturation. D) Assess level of alertness. | B. Monitoring of hourly urine output is included in nursing assistant education and does not require special clinical judgment. The nurse evaluates the results. |
| caring for obtunded client with shock of unknown origin, which action is first? A) Obtain IV access, and hang prescribed fluid infusions. B) Apply the automatic bp cuff. C) Assess LOC and pupil reaction to light. D) Check the airway and resp status. | D. When caring for any client, determining airway and respiratory status is priority. |
| which clinical symptoms in the postoperative client indicate early sepsis with an excellent recovery rate if treated? A) Localized erythema and edema B) Low-grade fever and mild hypotension C) Low o2 sat and dec cognition D) Red output and an inc rr | B. Feedback: Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. |
| Which clients are at immediate risk for hypovolemic shock? Select all that apply. A) Unrestrained in motor vehicle accident B) Construction worker C) Athlete D) Surgical intensive care client E) 85-year-old with gastrointestinal virus | A,D,E |
| The client recovering from an open reduction of the femur feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? A)Temperature B) Pulse C) Respiration D) Blood pressure | A. A sign of early sepsis is low-grade fever. |
Created by:
smarti13