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[Osborn] chapter 61

Learning Outcomes [Number and Title ]


Learning Outcome 1
Compare and contrast the etiologies of anaphylactic,
cardiogenic, hypovolemic, neurogenic, and septic shock.
Learning Outcome 2
Describe the cellular alterations that occur in shock.
Learning Outcome 3
Describe the bodys response to shock.
Learning Outcome 4
Learning Outcome 5

Learning Outcome 6
Learning Outcome 7

Learning Outcome 8
Learning Outcome 9
Learning Outcome 10

Identify the factors that place a patient at risk of developing


shock.
Discuss the emergency care of the patient in shock, including
identification of the underlying cause; management of the
patients airway, breathing, and circulation; and selected
pharmacologic interventions.
Describe the acute care of the patient in shock, including
oxygen management, circulatory management, nutritional
management, skin care, and pain and sedation management.
Compare and contrast systemic inflammatory response
syndrome (SIRS), sepsis, and severe sepsis based on the
definition used by the American College of Chest
Physicians/Society of Critical Care Medicine.
Prioritize the treatment of the patient with SIRS and identify
strategies to prevent the development of SIRS.
Understand the etiologies, epidemiology, and management of
multiple organ dysfunction syndrome (MODS) as an end result
of shock and severe sepsis.
Prioritize the treatment of the patient with MODS and identify
strategies to prevent the development of MODS.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

1. When caring for a group of clients, the nurse observes which of the following clients for
signs and symptoms of hemorrhagic shock?

Client 6 hours postmastectomy


Client who had a DVT after a surgical procedure 2 years earlier
Client sustaining a transmural myocardial infarction 2 days ago
Client with coronary atherosclerosis who takes 81 mg of aspirin daily

Correct Answer: Client 6 hours postmastectomy


Rationale: Postoperative clients are at risk for hemorrhage; mastectomy clients typically have
drains whose output should be carefully documented. A past history of DVT is not pertinent to
hemorrhage, as DVT is caused by a clot. A large myocardial infarction may lead to cardiogenic
shock, not hemorrhage. The antiplatelet properties of aspirin may predispose to bleeding;
however, there is no indication of trauma or bleeding.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

2. The nurse is caring for a client with papillary muscle rupture. When assessing the
client, the nurse is alert to the development of symptoms related to _________ shock?
1.
2.
3.
4.

Cardiogenic
Anaphylactic
Neurogenic
Septic

Correct Answer: Cardiogenic


Rationale: The papillary muscle holds the valves in place and may be damaged during
MI, the most common reason for cardiogenic shock. Anaphylactic shock develops from
hypersensitivity reactions. Neurogenic shock results from spinal cord injury or
vasodilatation below the level of spinal anesthesia, and septic shock results from
overwhelming infection.
Cognitive Level: Application
Nursing Process: Assessment
Client need Category: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

3. The nurse is caring for a client with endocarditis who is receiving penicillin. The nurse
should be particularly attentive to recognize early symptoms of which of the following
types of shock?
1.
2.
3.
4.

Anaphylactic
Cardiogenic
Hypovolemic
Septic

Correct Answer: Anaphylactic


Rationale: A hypersensitivity to medications, particularly penicillins, may occur at any
time during initial or subsequent treatments with the drug. Cardiogenic shock results
from loss of pumping ability due to damage to the left ventricle such as after MI.
Hypovolemic shock results from decreased vascular fluid volume. Septic shock results
from overwhelming infections and the SIRS.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

4. When caring for a client in shock, the nurse recognizes that consequences of decreased
blood flow to the kidney will result in:
1.
2.
3.
4.

Azotemia.
Elevated ammonia level.
Hypokalemia.
Hyperglycemia.

Correct Answer: Azotemia.


Rationale: Impaired tissue perfusion to the kidney will result in decreased perfusion and
build up of nitrogenous wastes, or azotemia. Increased ammonia levels result from
decreased perfusion to the liver. Hypokalemia does not typically appear in a shock state
with metabolic acidosis; hyperkalemia may be present. Hyperglycemia is related to stress
response and catecholamine release, not poor renal tissue perfusion.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

5. The nurse is caring for a client who has developed septic shock related to cancer
chemotherapy. The nurse recognizes changes in mental status most likely result from:
1.
2.
3.
4.

Decreased tissue oxygenation.


Metastasis of underlying cancer.
Anxiety about and fear of death.
A result of chemotherapy.

Correct Answer: Decreased tissue oxygenation.


Rationale: Clients at risk for septic shock include those who are immunosuppressed, have
invasive technology, or infections. Metastasis to the brain may cause confusion, but not
sepsis. Anxiety and fear may lead to confusion, but not sepsis. Chemo brain has been
documented as a cause of confusion, but not sepsis.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

6. The nurse is evaluating acidbase status in a client with septic shock. Which of the
following alterations is anticipated?
1.
2.
3.
4.

HCO3 of 10 mEq/L
pH of 7.46
pCO2 of 35 mm HG
pO2 of 77 mm HG

Correct Answer: HCO3 of 10 mEq/L


Rationale: Septic shock results in lactic acidosis secondary to tissue hypoxia, which is
manifested in a decreased bicarbonate level. A pH of 7.46 is normal. A pCO2 of 35 mm is
normal. A pO2 of >7580 is normal.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

7. The family of a client in shock asks why the clients hands are cold. The nurses best
response is which of the following?
1. Blood vessels constrict in shock, which takes the blood away from hands and
feet.
2. We keep the intensive care unit cool to reduce clients metabolic rate.
3. Your family member has developed a fever and chills.
4. This happens frequently to clients in shock states.
Correct Answer: Blood vessels constrict in shock, which takes the blood away from
hands and feet.
Rationale: Vasoconstriction results from catecholamine release, which is a compensatory
mechanism in shock. Cooling measures are used in shock for fever; the ICU is not
purposefully chilled. There is no indication that the client has developed fever and chills.
Stating that cold hands happen frequently does not answer the family members question.
Cognitive Level: Application
Nursing Process: Implementation
Physiological Integrity
Client Need:
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

8. The nurse anticipates that catecholamine release in shock may result in which of the
following?
1.
2.
3.
4.

Hyperglycemia
Bradycardia
Pinpoint pupils
Thirst

Correct Answer: Hyperglycemia


Rationale: Catecholamine release causes breakdown of glycogen to glucose, leading to
hyperglycemia. Bradycardia is not a consequence of catecholamine release; tachycardia
is. Pinpoint pupils are not a result of catecholamine release; mydriasis is. Thirst is a
symptom of hypovolemic shock; it is not specific to catecholamine release.
Cognitive Level: Application
Nursing Process: Assessment
Physiological Integrity
Client Need:
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

9. When assessing a client in shock who takes a beta adrenergic blocker, the nurse
recognizes that which of the following responses to shock may be altered?
1.
2.
3.
4.

Tachycardia
Hypotension
Bowel sound
Cyanosis

Correct Answer: Tachycardia


Rationale: Beta adrenergic blockers inhibit the sympathetic nervous system, causing
bradycardia. Hypotension will still occur with beta-blocker therapy, as the therapeutic
effect of a beta blocker is to reduce blood pressure. Beta-blockers may cause
constipation; decreased bowel sounds are expected in shock states. Cyanosis will still
occur in a shock state, as beta-blockers do not interfere with symptoms of poor
oxygenation.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

10. The nurse is evaluating the clients in an intensive care unit for risk for sepsis and
septic shock. Clients at risk for sepsis include the client:
Select all that apply.
1.
2.
3.
4.
5.

From a nursing home with a stage 4 pressure ulcer.


With rheumatoid arthritis taking methotrexate.
With aplastic anemia.
With blunt trauma spinal cord injury.
With ruptured viscus vomiting bright red blood.

Correct Answer:
1. From a nursing home with a stage 4 pressure ulcer.
2. With rheumatoid arthritis taking methotrexate.
3. With aplastic anemia.
Rationale: From a nursing home with stage 4 pressure ulcer. Breaches in skin
integrity such as pressure ulcers are risks for sepsis and septic shock. With rheumatoid
arthritis taking methotrexate. Clients such as those taking methotrexate for
chemotherapy or immune modulation are at risk for sepsis and septic shock. With
aplastic anemia. Aplastic anemia results in suppression of all cellular elements of the
bone marrow, including WBCs, which puts the client at risk for infection and sepsis.
With blunt trauma spinal cord injury. Blunt spinal cord injury may lead to spinal or
neurogenic shock. With ruptured viscus vomiting bright red blood. Fluid-volume
deficit secondary to hematemesis may lead to hypovolemic shock.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

11. When caring for a group of critically ill clients, the nurse recognizes that which of the
following patients has risk for increased mortality from sepsis?
1.
2.
3.
4.

A 20-year-old student with diabetes


A 32-year-old accountant with a head cold
A 60-year-old homemaker
A 40-year-old with hyperparathyroidism

Correct Answer: A 20-year-old student with diabetes


Diabetes increases the risk of death from sepsis, as hyperglycemia promotes
inflammation and increases the risk of ODS and death. Others at risk are those of
advanced age, patients with cancers, and the immunosuppressed client. A head cold, a
homemaker, and hyperparathyroidism do not have the same risks for death as the clients
previously described.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

12. The nurse is caring for a group of clients in a critical care unit. Which of the
following clients does the nurse identify as at risk for hypovolemic shock?
Select all that apply.
1.
2.
3.
4.
5.

Client with ruptured abdominal aortic aneurysm


Client with cirrhosis, ascites, and anasarca
Client in a multivehicle collision
Client sustaining a myocardial infarction
Client with systemic lupus erythematosus

Correct Answer:
1. Client with ruptured abdominal aortic aneurysm
2. Client with cirrhosis, ascites, and anasarca
3. Client in a multivehicle collision
Rationale: Client with ruptured abdominal aortic aneurysm. Clients at risk for
hypovolemic shock include those with hemorrhage and GI bleeding. Client with
cirrhosis, ascites, and anasarca. Clients at risk for hypovolemic shock include those
with hemorrhage, GI bleeding, third spacing, and unreplaced fluid loss. Client in a
multivehicle collision. Clients at risk for hypovolemic shock include those with
abdominal injury or trauma. Client sustaining a myocardial infarction. A myocardial
infarction may lead to cardiogenic, not hypovolemic, shock. Client with systemic lupus
erythematosus. A client treated for lupus typically takes immunosuppressing drugs such
as corticosteroids, placing the client at risk for septic shock.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

13. The nurse is caring for an 80-year-old client with septic shock admitted from a
nursing home earlier today. Which of the following should the nurse consider the most
likely source of the sepsis?
1.
2.
3.
4.

An indwelling Foley catheter inserted by nursing home personnel


An intravenous catheter inserted in the field
A red, flat rash in the perineal area
Exposure to the clients daughter who is receiving chemotherapy

Correct Answer: An indwelling Foley catheter inserted by nursing home personnel


Rationale: A major cause of sepsis is indwelling urinary catheters. An intravenous
catheter inserted in the field would not cause sepsis if just inserted. A perineal rash
without open skin will not contribute to sepsis. The clients daughter who receives
chemotherapy is at risk for infection and sepsis, not the client.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

14. When caring for a client with suspected cardiogenic shock, which of the following
would be most helpful in confirming the underlying cause?
1.
2.
3.
4.

Monitoring cardiac enzymes


Monitoring mean arterial pressure using an intra-arterial line
Measuring the central venous pressure
Monitoring pulmonary artery pressure

Correct Answer: Monitoring cardiac enzymes


Rationale: Measuring cardiac enzymes will determine the presence of myocardial
infarction, the major cause of cardiogenic shock. Arterial pressure monitoring is useful in
all shock states, but is not specific to cardiogenic shock. Central venous pressure assesses
fluid volume, and is not specific to cardiogenic shock. Pulmonary artery pressures assess
for pulmonary artery hypertension and fluid volume, and are not specific to cardiogenic
shock.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

15. When caring for a patient who was stabbed in the abdomen, the nurse recognizes that
2 liters of fluid given over the last hour have been ineffective when the patient displays
which of the following?
1.
2.
3.
4.

Heart rate 142 and regular


Blood pressure 94/50
Urine output of 45 ml for this hour
Patient complains of abdominal pain

Correct Answer: Heart rate 142 and regular


Rationale: Evidence of successful fluid resuscitation includes heart rate <110, presence
and strength of peripheral pulses, restoration of BP to >90 mmHG systolic, urine output
of at least 30 ml/hour or 0.4 to 1.0 ml/kg/hour. Presence of abdominal pain is not an
outcome criterion for shock.
Cognitive Level: Analysis
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

16. When admitting a client with septic shock, the nurse focuses on which of the
following potential causes in the patients history?
1.
2.
3.
4.

Client has received a liver transplant 3 months prior


Client underwent cholecystectomy last year
Client has a history of kidney stones
Client states he had a heart attack last month

Rationale: The client who has received an organ transplant must take immunosuppressant
drugs for the life of the transplant, which places the individual at risk for sepsis. A client
who has recovered from cholecystectomy, kidney stones, or MI is not at risk for sepsis.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

17. In order to protect the airway in a client with a Glasgow Coma Scale score of 3, the
nurse collaborates with the health care team to assist with which of the following?
1.
2.
3.
4.

Endotracheal intubation
Assessment of bowel sounds
Monitoring oxygen saturation
Questioning the client regarding difficulty breathing

Correct Answer: Endotracheal intubation


Rationale: A Glasgow Coma Scale score of 3 indicates a very decreased level of
consciousness; the priority is to protect the airway. Bowel sounds may be absent in
shock; the ABCs are addressed first. Questioning regarding difficulty breathing is not
done because the client is not verbal with a Glasgow Coma Scale score of 3.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

18. When caring for the client in septic shock, the nurse recognizes fluid replacement is
inadequate when which of the following is noted?
1.
2.
3.
4.

Urine output 10 milliliters for the last hour


Pulse rate of 100 beats per minute
MAP 75
Central venous pressure is 5 mmHG

Correct Answer: Urine output 10 milliliters for the last hour


Rationale: Adequate blood flow to the kidneys is measured by urine output of 0.5
ml/kg/hour. A heart rate of 100 is considered acceptable in shock. MAP should be kept >
65 mmHG. Normal CVP is 4 to 12.
Cognitive Level: Analysis
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

19. A client with hemorrhagic shock is receiving norepinephrine (Levophed) by


continuous infusion. Which of the following outcomes is anticipated?
1.
2.
3.
4.

Blood pressure of 100/54


Reduction in bleeding
Reduced apical heart rate
Decline in cardiac enzymes

Correct Answer: Blood pressure of 100/54


Rationale: Norpinephrine (Levophed) is a catecholamine used in shock to raise blood
pressure. Reduction in bleeding is not the intended effect; bleeding may actually increase
as blood pressure is restored. The apical pulse would increase related to the
catecholamine effects; therefore reduced heart rate is not the intended outcome. A decline
in cardiac enzymes is not anticipated, as norepinephrine increases afterload and cardiac
workload; this is not the intended effect.
Cognitive Level: Application
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

20. The nurse is caring for a client with septic shock. Which of the following findings is
present in septic shock?
1.
2.
3.
4.

Patient with infection, blood pressure 84/52 after 4 liters of saline


Patient with burns over 40% of the body and febrile
A patient with WBC count of 22,000 and fever
Patient with respiratory failure and community-acquired pneumonia

Correct Answer: Patient with infection, blood pressure 84/52 after 4 liters of saline
Rationale: By definition, septic shock exists when sepsis is refractory to fluid
resuscitation. A burn injury with fever does not meet the criteria for severe sepsis. A high
WBC count and fever may be present in an uncomplicated infection. Respiratory failure
secondary to pneumonia does not indicate presence of severe sepsis with shock.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

21. When caring for a client with sepsis, the nurse recognizes that which of the following
indicates a progression to severe sepsis?
Select all that apply.
1.
2.
3.
4.
5.

Client requires intubation and mechanical ventilation for respiratory failure


Blood pressure of 80/42 after 4 liters of fluid have been given
Hematuria, epistaxis, and oozing from central venous catheter site
WBC count of 4000 cells/cubic millimeter
Urine output of 40 to 60 milliliters per hour

Correct Answer:
1. Client requires intubation and mechanical ventilation for respiratory failure
2. Blood pressure of 80/42 after 4 liters of fluid have been given
3. Hematuria, epistaxis, and oozing from central venous catheter site
Rationale: Client requires intubation and mechanical ventilation for respiratory
failure. Severe sepsis is defined as the presence SIRS with hypotension/shock, a
confirmed infection, and single or multiple organ failure. Inability to manage
maintenance respiratory functions is consistent with a worsening condition. Blood
pressure of 80/42 after 4 liters of fluid have been given. Continuing hypotension after
the administration of treatment indicates a continuation of responses. Hematuria,
epistaxis, and oozing from central venous catheter site. Coagulopathy may be a
manifestation of worsening sepsis. WBC count of 4000 cells/cubic millimeter. A WBC
count of 4000 is normal. Urine output of 40 to 60 milliliters per hour. Urine output of
40 to 60 ml/hour (or 0.5 ml/kg/hour) is normal.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

21. The nurse is reviewing the diagnostic tests for a client with an infection. Which of the
following indicates the presence of sepsis?
1.
2.
3.
4.

Decreased activated protein C


Potassium 2.9 mEq/L
WBCs 5000 cells/cubic mm
Hemoglobin 8.5 gm/dL/Hematocrit 25.2%

Correct Answer: Decreased activated protein C


Rationale: A decreased activated protein C level is associated with sepsis, coagulopathy,
MODS, and increased mortality. Potassium levels are not specific to the diagnosis of
sepsis. WBC count of 5000 is normal. A low H & H indicates hemorrhage or destruction
of cells.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

22. The nurse plans to administer fluid to a client with SIRS and hypotension. Which of
the following orders should the nurse anticipate to prevent progression of shock?
1.
2.
3.
4.

Administer 1000 ml of lactated ringers over the next 2 hours.


Infuse 20 ml of D5 normal saline solution per hour.
Give 3% saline at a rate of 20 ml/hour.
Administer D5W at a rate of 100 ml/hour.

Correct Answer: Administer 1000 ml of lactated ringers over the next 2 hours.
Rationale: Isotonic solutions, such as normal saline or lactated ringers, should be
administered at a rate of 20 ml/kg/hr and increased to maintain urine output of 0.5
ml/kg/hr. D5 normal saline is a slightly hypertonic fluid; the rate of infusion is too low
for patients in shock. Three percent saline is hypertonic. D5W is a hypotonic solution.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 8

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

23. The critical care nurse is delivering a peer lecture on guidelines for the management
of SIRS and severe sepsis. Current evidence suggests which of the following will
improve outcome in septic shock?
1.
2.
3.
4.

Maintain blood glucose between 110 and 134 mg/dL


Antibiotic therapy initiated prior to end of shift
Mechanical ventilation with tidal volume of 10 ml/kg
Bicarbonate used for pH of 7.30

Correct Answer: Maintain blood glucose between 110 and 134 mg/dL
Rationale: Current evidence indicates that maintaining blood glucose <150 mg/dL
improves lipid levels and has anti-inflammatory and anticoagulant properties, improving
chances of survival. Antibiotic therapy should be initiated within the first hour of
identifying sepsis. Mechanical ventilation with tidal volumes of 4 to 6 liters/kg of normal
body weight improves outcome. Bicarbonate is not routinely used for acidosis.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 8

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

24. When caring for the client in septic shock, the nurse recognizes that current evidence
supports use of which of the following interventions to improve outcome?
1.
2.
3.
4.

Mechanical ventilation with a tidal volume of 4 to 6 ml/kg


Vasopressin instead of dopamine for hypotension
Limiting fluids to 3 liters per day
Positioning the client in high Fowlers position

Rationale: Current evidence suggests that maintaining mechanical ventilation with lowerthan-traditional tidal volumes of 4 to 6 ml/kg results in improved outcome. Vasopressin is
indicated when other pressors have failed to restore blood pressure. Fluid restriction is
indicated in cardiogenic shock. Positioning the client flat may be necessary to maintain
MAP.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 8

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

25. Which of the following interventions will reduce metabolic demands in a client with
multiple organ dysfunction syndrome?
1.
2.
3.
4.

Administer antipyretics for fever >101 degrees.


Place the client on a high-fat diet to increase energy.
Provide skin care and positioning to prevent breakdown.
Use meticulous hand hygiene and aseptic technique for procedures.

Correct Answer: Administer antipyretics for fever >101 degrees.


Rationale: Reducing fever will decrease metabolic rate and oxygen demand. A high-fat
diet is not indicated in shock; however, attention to nutrition and adequate calories is
necessary. Skin care and positioning are essential to prevent breakdown and further entry
of bacteria into the body, but will not reduce oxygen demands. Asepsis and hand washing
are essential to prevent further infection, but will not reduce oxygen demand.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 9

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

26. The nurse is caring for a client with septic shock and MODS. The clients family
member tearfully tells the nurse, The doctor said my mothers organs are shutting down.
How did that happen? Which of the following is the best response?
1.
2.
3.
4.

Deprivation of oxygen during shock causes organs to fail to function properly.


The infection attacks and destroys each organ, causing them to fail.
Fever damages the brain, which controls all organs.
The stress of illness has overwhelmed your loved one.

Correct Answer: Deprivation of oxygen during shock causes organs to fail to function
properly.
Rationale: The cascade of events in shock states results in inadequate tissue perfusion and
hypoxia leading to organ failure. Infection does not strike each organ; rather, an
inflammatory process begins a cascade of events impairing tissue perfusion that causes
organs to fail. Fever may cause brain damage if exceedingly high and increase metabolic
demand, increasing oxygen demand, but it is not the primary reason for MODS. The
stress response is activated as a compensatory mechanism; however, it is not the primary
reason for MODS.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 9

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

27. When planning care for a client with MODS secondary to septic shock, the nurse
suggests which of the following to the provider, as evidence shows a reduction in
mortality?
1.
2.
3.
4.

Recombinant activated protein C (xigris)


Heparin
Packed red blood cell transfusion
Dobutamine (Dobutrex)

Correct Answer: Recombinant activated protein C (xigris)


Rationale: Recombinant activated protein C (xigris) is indicated for clients with a high
risk of death, such as organ failure. Heparin is not typically used in the treatment of septic
shock. Packed red blood cell transfusions are used to increase the oxygen-carrying
capacity of the blood, such as after hemorrhage. Blood transfusions do not improve
survival in septic shock. Dobutamine is added in septic shock to improve cardiac output,
but has not been shown to improve survival.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 9

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

28. Which of the following is the priority for a client with MODS and adult respiratory
distress syndrome (ARDS)?
1.
2.
3.
4.

Maintain oxygen saturation 88% to 92%.


Provide mechanical ventilation with tidal volume of 10 ml/kg.
Administer sodium bicarbonate for pH of 7.31.
Provide frequent mouth care to prevent ventilator-associated pneumonia.

Correct Answer: Maintain oxygen saturation 88% to 92%.


Rationale: The goal of therapy in shock is to maintain tissue perfusion with oxygen
saturation 88% to 92% or more. Mechanical ventilation is provided with low tidal
volumes of 4 to 6 ml/kg. Bicarbonate is given for pH<7.1. Frequent mouth care is an
intervention, but not a higher priority than airway management.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 10

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

29. The nurse is caring for a client with MODS secondary to septic shock whose urine
output was 10 ml for the last 2 hours. Temperature is 97 degrees, pulse is 124 and
thready, and BP is 88/48. Which of the following orders is the priority at this time?
1.
2.
3.
4.

Administer isotonic fluids at 20 ml/kg/hr.


Draw blood for BUN and creatinine.
Place the client in a kinetic bed.
Place the client on a warming blanket.

Correct Answer: Administer isotonic fluids at 20 ml/kg/hr.


Rationale: The client has entered the cold or hypodynamic phase of shock characterized
by vasodilation and profound hypotension. Fluids are indicated to improve blood pressure
and blood flow through the kidney. BUN and creatinine may be evaluated to determine
the consequence of renal blood flow, but this is done after the ABCs have been addressed.
A kinetic bed will decrease pressure on the skin and prevent breakdown secondary to
decreased tissue perfusion, but is performed after the ABCs are addressed. A low body
temperature in the cold or hypodynamic phase is expected; warming may cause
vasodilation and lowered blood pressure. Treating the underlying cause of hypoperfusion
to the kidneys is indicated.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 10

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

30. Which of the following should take priority in a patient with MODS secondary to
severe sepsis?
1.
2.
3.
4.

pO2 of 54 mmHg
WBC count of 28,000 cell/cubic mm
Serum lactate level is 2 mmol/L
Blood glucose of 245 mg/dL

Correct Answer: pO2of 54 mmHg


Rationale: The nurse follows the ABCs for priority; a pO2 of 54 mmHg reflects
hypoxemia, the priority. A WBC count of 28,000 cells indicates infection; antibiotics are
begun within the first hour of identifying severe sepsis, but not before airway and
breathing are restored. A serum lactate level of 2 mmol/L is normal. Blood glucose level
should be controlled, but not before the airway and breathing are corrected.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 10

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.