NURS 2205C EXAM QUESTIONS WITH CORRECT ANSWERS:
Shock,Sepsisand Multiple Organ Dysfunction Syndrome
1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is
unable to auscultate a blood pressure. What is the best nursing action?
a. Assess the blood pressure by
Doppler. 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. Documenting a blood pressure as not assessable is not appropriate without further attempts
using different modalities.
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?
d. The patient is at risk for developing hypovolemic
shock. ANS: D
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.
5. A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110
beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates
administering
which therapeutic intervention?
c. Lactated Ringers bolus
ANS: C
The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated
Ringers 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.
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?
d. Low systemic vascular resistance and high cardiac
output 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.
8. Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?
c. A patient with a 2-day history of nausea, vomiting, and
diarrhea 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.
,NURS 2205C EXAM QUESTIONS WITH CORRECT ANSWERS:
Shock,Sepsisand Multiple Organ Dysfunction Syndrome
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 intervention?
a. Dobutamine (Dobutrex)
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 intervention?
b. Epinephrine 3 to 5 mL of a 1:10,000 solution
intravenously ANS: B
The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of
1:10,000 solution) is administered intravenously. Diphenhydramine (Benadryl) will help block histamine release, but
epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone (Solu-
Medrol), are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension.
Ranitidine (Zantac) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with
hypotension.
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 ANS: A
In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and
pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the
heart.
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.
12. During the initial stages of shock, what are the physiological effects of decreased cardiac output?
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.
13. While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority?
a. Central nervous
system ANS: A
The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes
early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and
,NURS 2205C EXAM QUESTIONS WITH CORRECT ANSWERS:
Shock,Sepsisand Multiple Organ Dysfunction Syndrome
respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest
indication of decreased perfusion.
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. ANS: A
The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts
through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and
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.
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?
a. Cardiac index (CI) of 2.5 L/min/m2
ANS: A
Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of
myocardial ischemia (chest pain, ST-segment 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.
16. The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident.
The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patients
skin
is warm and flushed. What is the best interpretation of these findings by the nurse?
a. The patient is developing neurogenic
shock. ANS: A
The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity.
There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop
from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical
situation.
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 patients plan of care?
c. Application of slow rewarming
measures 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 patients oxygen saturation is 95% on room air with an adequate
respiratory rate. The application of 100% oxygen via facemask is not indicated. The patients heart rate is adequate to
support a normal blood pressure.
20. The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic
shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42
breaths/min, and temperature 100.6 F. What is the best action by the nurse?
c. Titrate rate of blood administration to patient
response. ANS: C
, NURS 2205C EXAM QUESTIONS WITH CORRECT ANSWERS:
Shock,Sepsisand Multiple Organ Dysfunction Syndrome
Given the acute nature of the patients blood loss, the nurse should titrate the rate of the blood transfusion to an improvement
in the patients blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion
and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature
does not take priority over restoring circulating blood volume.
21. The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm
Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental
oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which
additional
physician order should the nurse complete first?
a. Blood cultures
ANS: A
Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following
obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and
measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.
24. The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure
of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg,
and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions
which order?
b. Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg
systolic. ANS: B
Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit. The
nurse should question the use of the dopamine (Intropin) infusion. All other listed orders are appropriate and have potential
for use in the treatment of a hypovolemic shock.
26. The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the
nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of
2200 dynes/sec/cm-5. Upon review of physician orders, which order is most appropriate for the nurse to initiate?
b. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest
pain ANS: B
The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease
the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a
nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order
options.
28. The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be
tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28
mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state?
d. pH 7.30, CO2 45, HCO3 18
ANS: D
As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic
metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All
other listed arterial blood gas values are within normal limits.
30. The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex).
The physicians order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse
measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the
nurse?
c. Reduce the rate of dobutamine (Dobutrex).
Shock,Sepsisand Multiple Organ Dysfunction Syndrome
1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is
unable to auscultate a blood pressure. What is the best nursing action?
a. Assess the blood pressure by
Doppler. 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. Documenting a blood pressure as not assessable is not appropriate without further attempts
using different modalities.
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?
d. The patient is at risk for developing hypovolemic
shock. ANS: D
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.
5. A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110
beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates
administering
which therapeutic intervention?
c. Lactated Ringers bolus
ANS: C
The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated
Ringers 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.
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?
d. Low systemic vascular resistance and high cardiac
output 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.
8. Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?
c. A patient with a 2-day history of nausea, vomiting, and
diarrhea 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.
,NURS 2205C EXAM QUESTIONS WITH CORRECT ANSWERS:
Shock,Sepsisand Multiple Organ Dysfunction Syndrome
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 intervention?
a. Dobutamine (Dobutrex)
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 intervention?
b. Epinephrine 3 to 5 mL of a 1:10,000 solution
intravenously ANS: B
The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of
1:10,000 solution) is administered intravenously. Diphenhydramine (Benadryl) will help block histamine release, but
epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone (Solu-
Medrol), are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension.
Ranitidine (Zantac) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with
hypotension.
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 ANS: A
In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and
pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the
heart.
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.
12. During the initial stages of shock, what are the physiological effects of decreased cardiac output?
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.
13. While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority?
a. Central nervous
system ANS: A
The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes
early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and
,NURS 2205C EXAM QUESTIONS WITH CORRECT ANSWERS:
Shock,Sepsisand Multiple Organ Dysfunction Syndrome
respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest
indication of decreased perfusion.
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. ANS: A
The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts
through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and
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.
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?
a. Cardiac index (CI) of 2.5 L/min/m2
ANS: A
Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of
myocardial ischemia (chest pain, ST-segment 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.
16. The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident.
The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patients
skin
is warm and flushed. What is the best interpretation of these findings by the nurse?
a. The patient is developing neurogenic
shock. ANS: A
The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity.
There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop
from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical
situation.
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 patients plan of care?
c. Application of slow rewarming
measures 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 patients oxygen saturation is 95% on room air with an adequate
respiratory rate. The application of 100% oxygen via facemask is not indicated. The patients heart rate is adequate to
support a normal blood pressure.
20. The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic
shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42
breaths/min, and temperature 100.6 F. What is the best action by the nurse?
c. Titrate rate of blood administration to patient
response. ANS: C
, NURS 2205C EXAM QUESTIONS WITH CORRECT ANSWERS:
Shock,Sepsisand Multiple Organ Dysfunction Syndrome
Given the acute nature of the patients blood loss, the nurse should titrate the rate of the blood transfusion to an improvement
in the patients blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion
and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature
does not take priority over restoring circulating blood volume.
21. The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm
Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental
oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which
additional
physician order should the nurse complete first?
a. Blood cultures
ANS: A
Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following
obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and
measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.
24. The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure
of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg,
and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions
which order?
b. Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg
systolic. ANS: B
Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit. The
nurse should question the use of the dopamine (Intropin) infusion. All other listed orders are appropriate and have potential
for use in the treatment of a hypovolemic shock.
26. The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the
nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of
2200 dynes/sec/cm-5. Upon review of physician orders, which order is most appropriate for the nurse to initiate?
b. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest
pain ANS: B
The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease
the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a
nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order
options.
28. The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be
tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28
mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state?
d. pH 7.30, CO2 45, HCO3 18
ANS: D
As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic
metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All
other listed arterial blood gas values are within normal limits.
30. The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex).
The physicians order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse
measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the
nurse?
c. Reduce the rate of dobutamine (Dobutrex).
