Test bank for introduction to critical care nursing 6th edition by sole

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2.. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Red

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a Assess the blood pressure by Doppler

b Estimate the systolic pressure as 60 mm Hg

c Obtain an electronic blood pressure monitor

d Record the blood pressure as “not assessable.”

ANS: A

Auscultated blood pressures in shock may be significantly inaccurate due to

vasoconstriction If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound If brachial pulses are palpable, the

approximate measure of systolic blood pressure is 80 mm Hg This action has the potential to delay further assessment of a compromised patient in shock

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Documenting a blood pressure as not assessable is not appropriate without further attempts using different modalities

DIF: Cognitive Level: Application REF: p 258

OBJ: Develop an individualized plan of care that includes nursing diagnosis,

expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2 The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis One hour later, which laboratory result requires immediate nursing action?

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DIF: Cognitive Level: Application REF: p 259 | Laboratory Alert

OBJ: Relate assessment findings to the classification and stage of shock

TOP: Nursing Process Step: Assessment

a Breath sounds and capillary refill

b Blood pressure and oral temperature

c Oral temperature and capillary refill

d Right atrial pressure and urine output

hypothermic or has peripheral circulatory problems Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in

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shock Capillary refill provides a quick assessment of the patient’s overall

cardiovascular status, but this assessment is not reliable in a patient who is

hypothermic or has peripheral circulatory problems

OBJ: Describe management strategies for each classification of shock

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

4 A patient is admitted to the critical care unit following coronary artery bypass surgery Two hours postoperatively, the nurse assesses the following

information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg;

pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr What is the best interpretation by the nurse?

a The assessed values are within normal limits

b The patient is at risk for developing cardiogenic shock

c The patient is at risk for developing fluid volume

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Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia Both urine output and chest drainage values are high, contributing to the hypovolemia Assessed values are not within normal limits

A cardiac output of 4 L/min is not indicative of cardiogenic shock The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output

DIF: Cognitive Level: Analysis REF: p 270 | Table 11-5

MSC: NCLEX: Physiological Integrity: Reduction of Risk

a Human albumin infusion

b Hypotonic saline solution

c Lactated Ringer’s bolus

d Packed red blood cells

ANS: C

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The patient is experiencing symptoms of hypovolemic shock Isotonic crystalloids, such as normal saline and lactated Ringer’s solutions, are the priority intervention Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation There is no evidence to support a

transfusion in the given scenario

TOP: Nursing Process Step: Intervention

6 The nurse is caring for a patient in the early stages of septic shock The

patient is slightly confused and flushed, with bounding peripheral pulses Which hemodynamic values is the nurse most likely to assess?

a High pulmonary artery occlusive pressure and high

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ANS: D

As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance In septic shock, pulmonary artery occlusion pressure is not elevated In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high In the early stages of septic shock, cardiac output is high

DIF: Cognitive Level: Knowledge REF: p 270 | Table 11-5

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7 The nurse is caring for a patient admitted with severe sepsis Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg Assuming physician orders, which intervention should the nurse carry out first?

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ANS: D

Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min Fluid resuscitation to restore perfusion is the

immediate priority Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario

DIF: Cognitive Level: Analysis REF: p 270

8 Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?

a A patient admitted with abdominal pain and an

elevated white blood cell count

b A patient with a temperature of 102° F and a general

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ANS: C

Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia There is no evidence to support significant fluid loss in the remaining patient scenarios

DIF: Cognitive Level: Comprehension REF: p 270

9 The nurse is caring for a patient admitted with cardiogenic shock

Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2 What is the priority pharmacological

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ANS: A

Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart As contractility increases, cardiac output and index increase and improve tissue perfusion Administration of furosemide will assist only in managing fluid volume overload Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output Sodium

nitroprusside is given to reduce afterload There is no evidence to support a need for afterload reduction in this scenario

10 Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min What is the priority

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DIF: Cognitive Level: Analysis REF: p 271, 278 | Table 11-5

11 A patient is admitted to the cardiac care unit with an acute anterior

myocardial infarction The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields Following insertion of a pulmonary artery catheter by the physician, which

hemodynamic values is the nurse most likely to assess?

a High pulmonary artery diastolic pressure and low

cardiac output

b Low pulmonary artery occlusive pressure and low

cardiac output

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c Low systemic vascular resistance and high cardiac

Pulmonary artery occlusion pressure increases in cardiogenic shock Systemic vascular resistance is high and cardiac output is low in cardiogenic shock Cardiac output is low and systemic vascular resistance is high in cardiogenic shock

DIF: Cognitive Level: Analysis REF: p 275

12 During the initial stages of shock, what are the physiological effects of decreased cardiac output?

a Arterial vasodilation

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b High urine output

c Increased parasympathetic stimulation

d Increased sympathetic stimulation

ANS: D

A reduction in blood pressure leads to an increase in catecholamine release,

resulting in an increase in heart rate and contractility to improve cardiac output Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure Low urine output results, as decreased cardiac output reduces blood flow to the kidneys There is an increase in sympathetic stimulation in response to a decrease in cardiac output

DIF: Cognitive Level: Knowledge REF: p 258

OBJ: Correlate the four classifications of shock to their pathophysiology

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DIF: Cognitive Level: Knowledge REF: p 257

14 The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP) The family inquires about the primary reason for the device What is the best statement by the nurse to explain the IABP?

a “The action of the machine will improve blood supply

to the damaged heart.”

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b “The machine will beat for the damaged heart with

every beat until it heals.”

c “The machine will help cleanse the blood of impurities

that might damage the heart.”

d “The machine will remain in place until the patient is

ready for a heart transplant.”

backward blood flow It does not “beat” for the damaged heart An IABP does not filter blood impurities An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective It is indicated for short-term use, not as a bridge to transplant

TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

15 The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy Which hemodynamic parameter best indicates an appropriate response to therapy?

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a Cardiac index (CI) of 2.5 L/min/m2

b Pulmonary artery diastolic pressure of 26 mm Hg

c Pulmonary artery occlusion pressure (PAOP) of 22

elevation), increased stroke volume, and increased cardiac output and cardiac index

A cardiac index of 2.5 L/min is within normal limits All other values are high and would not indicate an appropriate response to therapy

TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

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a The patient is developing neurogenic shock

b The patient is experiencing an allergic reaction

c The patient most likely has an elevated temperature

d The vital signs are normal for this patient

DIF: Cognitive Level: Analysis REF: pp 276-277

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

17 The nurse is caring for a patient in spinal shock Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24

breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F Which intervention is most important for the nurse to include in the patient’s plan of care?

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a Administration of atropine sulfate (Atropine)

b Application of 100% oxygen via facemask

c Application of slow rewarming measures

d Infusion of IV phenylephrine (Neo-Synephrine)

ANS: C

Hypothermia can develop in neurogenic shock from uncontrolled heat loss;

therefore, a patient should be rewarmed slowly to avoid further vasodilation In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered

hypotensive Atropine is used for symptomatic bradycardia The patient’s oxygen saturation is 95% on room air with an adequate respiratory rate The application of 100% oxygen via facemask is not indicated The patient’s heart rate is adequate to support a normal blood pressure

18 The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110

beats/min, urine output of 10 mL for the past hour, and a central venous

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