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Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous

pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg. ANS: A

Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock require large amounts of fluid replacement. If the patient remains hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of

92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg. ANS: B

The patient’s elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. A patient with massive trauma and possible spinal cord injury is admitted to the emergency

department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles c. Cool, clammy extremities b. Heart rate 45 beats/min d. Temperature 101.2°F (38.4°C) ANS: B

Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

DIF: Cognitive Level: Understand (comprehension) REF: 1590 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring

indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion. ANS: C

Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. After receiving 2 L of normal saline, the central venous pressure for a patient who has septic

shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. furosemide . c. norepinephrine . b. nitroglycerin . d. sodium nitroprusside . ANS: C

When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with

systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? c. Check stools for occult blood. d. Palpate for abdominal tenderness.

a. Auscultate bowel sounds. b. Ask the patient about nausea. ANS: C

Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration. DIF: Cognitive Level: Apply (application) REF: 1606 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 7. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128,

respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication?

a. 5% albumin infusion b. furosemide (Lasix) IV

c. epinephrine (Adrenalin) drip d. hydrocortisone (Solu-Cortef)

ANS: B

The PAWP indicates that the patient’s preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 8. The emergency department (ED) nurse receives report that a seriously injured patient involved

in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient’s arrival, the nurse will obtain a. a dopamine infusion. c. lactated Ringer’s solution. b. a hypothermia blanket. d. two 16-gauge IV catheters. ANS: D

A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer’s solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 9. Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with

hypovolemic shock has been effective? Hemoglobin is within normal limits. Urine output is 65 mL over the past hour. Central venous pressure (CVP) is normal. Mean arterial pressure (MAP) is 72 mm Hg.

a. b. c. d.

ANS: B

Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. DIF: Cognitive Level: Analyze (analysis) REF: 1589 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic

shock? Check temperature every 2 hours. Monitor breath sounds frequently. Maintain patient in supine position. Assess skin for flushing and itching.

a. b. c. d.

ANS: B

Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock. DIF: Cognitive Level: Apply (application) REF: 1591 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. Norepinephrine has been prescribed for a patient who was admitted with dehydration and

hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient’s central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since being admitted. ANS: B

Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient’s low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration. DIF: Cognitive Level: Apply (application) REF: 1598 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic

shock. Which finding indicates that the drug is effective? c. Warm, pink, and dry skin d. Blood pressure of 92/40 mm Hg

a. No new heart murmurs b. Decreased troponin level ANS: C

Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 13. Which assessment information is most important for the nurse to obtain when evaluating

whether treatment of a patient with anaphylactic shock has been effective? c. Blood pressure d. Oxygen saturation

a. Heart rate b. Orientation ANS: D

Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock. DIF: Cognitive Level: Analyze (analysis) REF: 1600 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

14. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that

the patient may be developing multiple organ dysfunction syndrome (MODS)? The patient’s serum creatinine level is elevated. The patient complains of intermittent chest pressure. The patient’s extremities are cool and pulses are weak. The patient has bilateral crackles throughout lung fields.

a. b. c. d.

ANS: A

The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient’s diagnosis of cardiogenic shock. DIF: Cognitive Level: Apply (application) REF: 1591 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of

32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg. ANS: A

Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well. DIF: Cognitive Level: Analyze (analysis) REF: 1600 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for

patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Maintaining a cool room temperature for a patient with neurogenic shock d. Increasing the nitroprusside infusion rate for a patient with a very high SVR ANS: C

Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Apply (application) REF: 1590 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 17. The nurse is caring for a patient who has septic shock. Which assessment finding is most

important for the nurse to report to the health care provider? c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

a. Skin cool and clammy b. Heart rate of 118 beats/min

ANS: A

Because patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient’s status. DIF: Cognitive Level: Analyze (analysis) REF: 1594 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 18. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The

first action by the nurse should be to obtain the blood pressure. check the level of orientation. administer supplemental oxygen. obtain a 12-lead electrocardiogram.

a. b. c. d.

ANS: C

The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation— and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2. DIF: Cognitive Level: Analyze (analysis) REF: 1597 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. During change-of-shift report, the nurse is told that a patient has been admitted with

dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion c. Heart rate 112 beats/min b. Decreased bowel sounds d. Pale, cool, and dry extremities ANS: A

The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock. DIF: Cognitive Level: Analyze (analysis) REF: 1597 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A patient who has been involved in a motor vehicle crash arrives in the emergency department

(ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring. ANS: B

The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented. DIF: Cognitive Level: Analyze (analysis) REF: 1597 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. A patient who has neurogenic shock is receiving a phenylephrine infusion through a right

forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient’s heart rate is 58 beats/min. b. The patient’s extremities are warm and dry. c. The patient’s IV infusion site is cool and pale. d. The patient’s urine output is 28 mL over the past hour. ANS: C

The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action. DIF: Cognitive Level: Analyze (analysis) REF: 1599 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22. The following interventions are ordered by the health care provider for a patient who has

respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Give epinephrine. b. Administer diphenhydramine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count (CBC) ANS: A

Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed. DIF: Cognitive Level: Analyze (analysis) REF: 1599 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. Which finding about a patient who is receiving vasopressin to treat septic shock indicates an

immediate need for the nurse to report the finding to the health care provider? a. The patient’s urine output is 18 mL/hr.

b. The patient is complaining of chest pain. c. The patient’s peripheral pulses are weak. d. The patient’s heart rate is 110 beats/minute. ANS: B

Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient’s diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 24. After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in

the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures

and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate

of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and

a blood pressure of 108/58 mm Hg ANS: B

Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually requir...