Shock Exams

Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 69: Nursing Management: Emergency and Disaster Nursing
MULTIPLE CHOICE
1. Four victims of an automobile crash are brought by ambulance to the emergency department (emergency department). The triage nurse
determines that the victim who has the highest priority for treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture with profuse bleeding.
c. a sucking chest wound.
d. absence of peripheral pulses.
Correct Answer: C
Rationale: Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be
treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also
need rapid intervention but do not have airway or breathing problems.
Cognitive Level: Application Text Reference: p. 1823

Nursing Process: Assessment NCLEX: Physiological Integrity
2. A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, “I had a temperature of
104.6º F (40.3º C) at home.” The nurse’s first action should be to
a. tell the patient that it may be several hours before being seen by the doctor.
b. assess the patient’s current vital signs.
c. obtain a clean-catch urine for urinalysis.
d. ask the health care provider to order a nonopioid analgesic medication for the patient.
Correct Answer: B
Rationale: The patient’s pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how
rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with more useful
data for triage. The health care provider will not order a medication before assessing the patient.
Cognitive Level: Application Text Reference: pp. 1822-1823

3. During the primary assessment of a trauma victim, the nurse determines that the patient has a patent airway. The next assessment by the
nurse should be to
a. check the patient’s level of consciousness.
b. examine the patient for any external bleeding.
c. observe the patient’s respiratory effort.
d. palpate for the presence of peripheral pulses.
Correct Answer: C
Rationale: Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient’s
breathing. The other actions are also part of the initial survey but are not accomplished as rapidly as the assessment of breathing.

4. During the primary assessment of a patient with multiple trauma, the nurse observes that the patient’s right pedal pulses are absent and the
leg is swollen. The nurse’s first action should be to
a. initiate isotonic fluid infusion through two large-bore IV lines.
b. send blood to the lab for a complete blood count (CBC).
c. finish the airway, breathing, circulation, disability survey.
d. assess further for a cause of the decreased circulation.
Correct Answer: A
Rationale: The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is
found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is
indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after
the IV fluids are initiated.

Nursing Process: Implementation NCLEX: Physiological Integrity
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

5. When caring for a patient with head and neck trauma after a motorcycle accident, the emergency department nurse’s first action should be
to
a. suction the mouth and oropharynx.
b. immobilize the cervical spine.
c. administer supplemental oxygen.
d. obtain venous access.
Correct Answer: B
Rationale: When there is a risk of spinal cord injury, the nurse’s initial action is immobilization of the cervical spine during positioning of the
head and neck for airway management. Suctioning, supplemental oxygen administration, and venous access are also necessary after the cervical
spine is protected by immobilization.

6. A patient has been brought to the emergency department with a gunshot wound to the abdomen. In obtaining a history of the incident to
determine possible injuries, the nurse asks
a. “Where did the incident occur?”
b. “What direction did the bullet enter the body?”
c. “How long ago did the incident happen?”
d. “What emergency care was started at the scene?”
Correct Answer: B
Rationale: The entry point and direction of the bullet will help to predict the type of injuries the patient has. The other information is not as
useful in determining which diagnostic studies and care are needed immediately.

7. A 67-year-old patient who has fallen from a ladder is transported to the emergency department by ambulance. The patient is unconscious on
arrival and accompanied by family members. During the primary survey of the patient, the nurse should
a. assess the patient’s vital signs.
b. obtain a Glasgow Coma Scale score.
c. attach a cardiac ECG monitor.
d. ask about chronic medical conditions.
Correct Answer: B
Rationale: The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the
secondary survey.

8. A 24-year-old is brought to the emergency department with multiple lacerations and tissue avulsion of the right hand after catching the hand
in a produce conveyor belt. When asked about tetanus immunization, the patient says, “I’ve never had any vaccinations.” The nurse will
anticipate administration of tetanus
a. immunoglobulin.
b. and diphtheria toxoid.
c. immunoglobulin, tetanus-diphtheria toxoid, and pertussis vaccine.
d. immunoglobulin and tetanus-diphtheria toxoid.
Correct Answer: C
Rationale: For a patient with unknown immunization status, the tetanus immune globulin is administered along with the Tdap (since the patient
has not had pertussis vaccine previously). The other immunizations are not sufficient for this patient.

Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
9. A patient has experienced blunt abdominal trauma from a motor vehicle accident. The nurse should explain to the patient the purpose of
a. magnetic resonance imaging (MRI).
b. ultrasonography.
c. peritoneal lavage.
d. nasogastric (NG) tube placement.

Correct Answer: B
Rationale: If intra-abdominal bleeding is suspected, focused abdominal ultrasonography is obtained to look for intraperitoneal bleeding. MRI
would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intra-abdominal
bleeding.

Nursing Process: Planning NCLEX: Physiological Integrity
10. A patient is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the
patient is taken into a treatment room and asks to stay with the patient. The nurse should
a. have the spouse wait outside the treatment room with a designated staff member to provide emotional support.
b. bring the spouse into the room and ensure him or her that a member of the team will explain the care given and answer
questions.
c. explain that the presence of family members is distracting to staff and might impair the resuscitation efforts.
d. advise the spouse that if the resuscitation effort is unsuccessful, the memories may have an adverse impact on grieving.
Correct Answer: B
Rationale: Family members and patients report benefits from family presence during resuscitation efforts, so the nurse should try to
accommodate the spouse. Having the spouse wait outside the room is not as supportive to the spouse or patient. It would be inappropriate to
imply that the spouse’s presence would have adverse consequences for the patient. Family members do not report problems with grieving caused
by being present during resuscitation efforts.

Nursing Process: Implementation NCLEX: Psychosocial Integrity
11. During the summer, a patient with heat cramps is treated in the emergency department. The nurse determines that discharge teaching
regarding the prevention of another episode of heat cramps has been effective when the patient states,
a. “I will take salt tablets when I work outdoors in the summer.”
b. “I should double my water intake when the weather gets warm.”
c. “I should have sports drinks when exercising outside in hot weather.”
d. “I will get into a cool environment if I notice that I am feeling confused.”
Correct Answer: C
Rationale: Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not
recommended because of the risks of gastric irritation and hypernatremia. It is not necessary to double one’s water intake simply when the
weather is warm. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.

Nursing Process: Evaluation NCLEX: Physiological Integrity
12. An unresponsive 78-year-old patient is admitted to the emergency department in a coma during a summer heat wave. The patient’s core
temperature is 106.2° F (41.2° C), blood pressure (BP) 86/52, and pulse 102. The nurse will plan to
a. apply wet sheets and a fan to the patient.
b. administer an acetaminophen (Tylenol) suppository.
c. start O2 at 6 L/min with a nasal cannula.
d. infuse lactated Ringer’s solution at 1000 ml/hr.
Correct Answer: A
Rationale: The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100%
oxygen should be given, which requires a high flow rate through a non-rebreathing mask. An older patient would be at risk for developing
complications such as pulmonary edema if given fluids at 1000 ml/hr.

13. A 77-year-old patient is brought into the emergency department unconscious and with a core temperature of 89° F (31.6° C). During
rewarming measures, the nurse determines that the goals of treatment are being met when the patient
a. has a core temperature of 95° F (35° C).
b. shivers involuntarily to raise body temperature.
c. regains consciousness.
d. has a blood pH within normal limits.
Correct Answer: A

Rationale: The improvement in the patient’s body temperature is the best indication that the goals of rewarming are being met. Shivering,
improvement in level of consciousness (LOC), and normalization of pH all might confirm that the patient’s condition is improving, but they are
not as clear as the elevation in temperature.

14. When preparing to rewarm a patient with hypothermia, the nurse will plan to
a. attach a cardiac monitor.
b. insert a urinary catheter.
c. assist with endotracheal intubation.
d. keep inotropic drugs available.
Correct Answer: A
Rationale: Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and
endotracheal intubation are not needed for rewarming. Cardiac inotropes tend to stimulate the heart and increase the risk for fatal dysrhythmias
such as ventricular fibrillation.

15. A patient is admitted to the emergency department after a near-drowning accident in a local lake. The patient received rescue breathing at
the site and now has spontaneous respirations. The nurse will observe the patient for several hours to monitor for symptoms of
a. hypernatremia.
b. pulmonary edema.
c. hypothermia.
d. head injury.
Correct Answer: B
Rationale: Pulmonary edema is a common complication after a near-drowning incident. Hypernatremia would not occur in a freshwater
submersion. Hypothermia and head injury may be associated with near-drowning but would be apparent at the time of admission and would not
develop after several hours.

16. All of the following actions are needed for a patient admitted with multiple bee stings to the hands. Which one will the nurse accomplish
first?
a. Give diphenhydramine (Benadryl) 100 mg po.
b. Apply calamine lotion to any itching areas.
c. Place ice packs on both hands.
d. Remove the patient’s rings.
Correct Answer: D
Rationale: The patient’s rings should be removed first because it might not be possible to remove them if swelling develops. The other orders
should also be implemented as rapidly as possible after the nurse has removed the jewelry.

17. An unconscious patient is admitted to the emergency department 45 minutes after ingesting approximately 30 diazepam (Valium) tablets.
The health care provider prescribes gastric lavage. The first action the nurse will plan when implementing the order is to
a. position the patient on his or her side.
b. insert a large-bore nasogastric tube.
c. assist the health care provider to intubate the patient.
d. prepare a 60-ml syringe with saline.
Correct Answer: C
Rationale: An unconscious patient cannot protect the airway and is at risk for aspiration during gastric lavage, so intubation is done before
starting the lavage. Positioning the patient on his or her side will decrease the risk for aspiration, but the patient will need to be supine for
intubation. An orogastric tube is used for gastric lavage. The saline will be injected after the intubation.

NCLEX: Safe and Effective Care Environment

18. A patient is admitted to the emergency department with multiple bruises of the face and arms and an obvious deformity of the right upper
arm. A friend accompanying the patient tells the nurse that the patient’s spouse was responsible for the injuries. The nurse’s role in this
patient’s care is
a. to inform the patient of safe houses and other options.
b. to encourage the friend to have the patient report the abuse.
c. to notify the local law enforcement agency.
d. limited to the treatment of the patient’s injuries.
Correct Answer: A
Rationale: The nurse’s role includes informing victims of domestic violence about options and safe housing. The nurse should speak directly to
the patient about the option of reporting the abuse to the police (after further assessment of the patient). A competent adult patient is responsible
for reporting abuse to the police. The nurse is responsible for assessing for domestic violence and making appropriate referrals in addition to
providing care for the physical injuries.
Cognitive Level: Comprehension Text Reference: p. 1838

19. When planning the response to the potential use of smallpox as a biologic weapon, the emergency department manager will focus on
obtaining sufficient quantities of
a. blood.
b. antibiotics.
c. vaccine.
d. antitoxin.
Correct Answer: C
Rationale: Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other
interventions would be helpful for other biologic weapons, but not for smallpox.
Cognitive Level: Comprehension Text Reference: pp. 1838-1839

20. A patient arrives in the emergency department after exposure to radioactive dust. Which action should the nurse take first?
a. Place the patient in a shower.
b. Obtain the patient’s vital signs.
c. Determine the type of radioactive agent.
d. Obtain a baseline complete blood count.
Correct Answer: A
Rationale: The initial action should be to protect staff members and decrease the patient’s exposure to the radioactive agent by decontamination.
The other actions can be accomplished after the decontamination is completed.

21. When rewarming a patient who arrived in the emergency department with a temperature of 87° F, which assessment indicates that
rewarming should be stopped?
a. The patient develops atrial fibrillation.
b. The BP decreases to 85/40 mm Hg.
c. The core temperature is 95.2° F.
d. The axillary temperature reaches 96° F.
Correct Answer: C
Rationale: A core temperature of 95° F is an indication that sufficient rewarming has occurred. Dysrhythmias and hypotension may occur during
rewarming and should be treated but are not an indication to stop rewarming the patient. The patient’s core temperature, rather than the axillary
temperature, is used to determine the success of rewarming procedures.

22. When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first?
a. Lung sounds
b. Oxygen saturation
c. Body temperature
d. Apical pulse

Correct Answer: B
Rationale: The priority assessment data are how well the patient is oxygenating, so O2 saturation should be obtained first because this measure
gives the most direct information. The other data will also be collected rapidly but are not as essential as the O 2 saturation.

23. A patient arrives at the emergency department after being bitten by a poisonous snake. Initially, the nurse will plan to
a. start a large-bore IV line.
b. administer analgesics.
c. draw blood for laboratory testing.
d. administer tetanus prophylaxis.
Correct Answer: A
Rationale: Because hypovolemic shock and hemolysis can occur with snakebite, it is important to be able to administer large amounts of IV
fluids rapidly. Analgesic administration, drawing blood, and administration of tetanus prophylaxis can be accomplished later.

24. When assessing a patient admitted to the emergency department with a broken arm and facial bruises, the nurse notes multiple additional
bruises in various stages of healing. Which statement or question by the nurse is most appropriate?
a. “You should not return to your home.”
b. “I have to report this abuse to the police.”
c. “Would you like to see a social worker?”
d. “Is someone at home hurting you?”
Correct Answer: D
Rationale: The nurse’s initial response should be to further assess the patient’s situation. Telling the patient not to return home may be an option
once further assessment is done. The patient, not the nurse, is responsible for reporting the abuse. A social worker may be appropriate once
further assessment is completed.

OTHER
1. These four patients arrive in the emergency department after a motor-vehicle crash. In which order should they been assessed?
a. A 22-year-old with fractures of the face and jaw
b. A 30-year-old with a misaligned right leg
c. A 45-year-old complaining of 6/10 abdominal pain
d. A 72-year-old with palpitations and chest pain
Correct Answer: A, D, C, B
Rationale: The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-
old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pains. The 45-year-old patient
may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture
of the right leg and should be seen soon, but this patient has the least life-threatening injury.

Test Bank
Chapter 66: Nursing Management: Critical Care
MULTIPLE CHOICE
1. Several family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just
arrived in the ICU waiting room. Which action should the nurse take first?
a. Take the family member members to the patient’s room.
b. Describe the patient’s injuries and the care that is being provided.
c. Discuss ICU visitation policies and encourage family visits.
d. Invite the family to participate in a multidisciplinary care conference.
Correct Answer: B

Rationale: Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be
prepared for the patient’s appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized
to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference
is appropriate but should not be the initial action by the nurse.

Nursing Process: Implementation NCLEX: Psychosocial Integrity
2. The nurse identifies a nursing diagnosis of disturbed sensory perception related to sleep deprivation for a patient in the ICU. An appropriate
nursing intervention for this problem is to
a. cluster nursing activities so that the patient has uninterrupted rest periods.
b. administer prescribed sedatives or opioids at bedtime to promote sleep.
c. silence the alarms on the cardiac monitors to allow the patient to take 30- to 40-minute naps.
d. discontinue assessments during the night to allow uninterrupted rest for the patient.
Correct Answer: A
Rationale: Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioids
medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory
perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the
night.

3. During hemodynamic monitoring, the nurse finds that a patient has decreased cardiac output (CO) without changes in pulmonary artery
wedge pressure (PAWP) or systemic vascular resistance (SVR). The nurse anticipates assisting with interventions to
a. reduce stroke volume.
b. increase heart rate.
c. lower right atrial pressure (RAP).
d. reduce central venous pressure (CVP).
Correct Answer: B
Rationale: The formula for CO is stroke volume  heart rate. Because the PAWP and SVR are unchanged, the patient’s stroke volume is stable,
so a drop in heart rate has occurred to decrease the CO. Measures to improve heart rate should be implemented. Interventions to reduce stroke
volume, lowering right atrial pressure, or reduce CVP are not indicated because the problem is the patient’s heart rate.

4. A patient in heart failure following an acute myocardial infarction has a pulmonary artery catheter inserted. To determine whether the
administration of drugs to decrease preload and afterload has been effective, the nurse should monitor the
a. systemic vascular resistance (SVR).
b. central venous pressure (CVP).
c. pulmonary vascular resistance (PVR).
d. pulmonary artery wedge pressure (PAWP).
Correct Answer: D
Rationale: Although all of these parameters will change after administration of drugs to reduce preload and afterload, a decrease in PAWP would
be the best indicator of a decrease in pressure and volume in the left ventricle at the end of diastole (and of resolving heart failure).

5. A patient with hemodynamic monitoring has a blood pressure of 94/68, heart rate of 130, and a cardiac output (CO) of 4.8 L/min. In
analyzing the patient’s hemodynamic measurements, the nurse calculates the stroke volume (SV) at ____ ml/beat.
a. 28
b. 37
c. 42
d. 59
Correct Answer: B
Rationale: The formula for CO is heart rate multiplied by stroke volume. Because the patient’s CO is 4.8 L/min and the heart rate is 130, the
stroke volume must be 37 ml/beat.

6. A patient admitted to the ICU after experiencing a massive pulmonary embolism has an arterial catheter and a pulmonary artery catheter in
place. When evaluating whether treatment has been effective in improving pulmonary hypertension, the nurse will monitor for
a. increased pulmonary artery pressure (PAP).
b. decreased pulmonary vascular resistance (PVR).
c. increased mean arterial pressure (MAP).
d. decreased pulmonary artery wedge pressure (PAWP).
Correct Answer: B
Rationale: Pulmonary vascular resistance (PVR) is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary
hypertension was improving. An increased pulmonary artery pressure (PAP) would indicate that the pulmonary hypertension was worsening.
Mean arterial pressure (MAP) is a reflection of systemic pressure and does not provide any direct evidence of any improvement in pulmonary
hypertension. Pulmonary artery wedge pressure (PAWP) reflects pressure in the left ventricle and is not useful in monitoring pulmonary
pressures.

7. The ICU charge nurse will evaluate that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new
nurse
a. balances and calibrates the hemodynamic monitoring equipment every hour.
b. ensures that the patient is lying supine with the head of the bed flat for all readings.
c. positions the zero-reference stopcock line level with the phlebostatic axis.
d. positions the limb with the catheter insertion site at zero-reference of the stopcock line.
Correct Answer: C
Rationale: For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and
recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patient’s head raised to 45 degrees or in the
prone position. The position of the limb and the catheter insertion site are not useful in zeroing the monitoring equipment.

Nursing Process: Evaluation
8. A patient with left ventricular failure is admitted to the coronary care unit (CCU). When monitoring for the effectiveness of treatment, the
most important information for the nurse to obtain is
a. systemic vascular resistance (SVR).
b. pulmonary vascular resistance (PVR).
c. mean arterial pressure (MAP).
d. pulmonary artery wedge pressure (PAWP).
Correct Answer: D
Rationale: Pulmonary artery wedge pressure (PAWP) reflects left ventricular end diastolic pressure (or left ventricular preload). Because the
patient in left ventricular failure will have a high PAWP, a decrease in this value will be the best indicator of patient improvement. The other
values would also provide useful information, but the most definitive measurement of improvement is a drop in PAWP.

9. A patient has an arterial pressure catheter placed in the right radial artery for access for frequent arterial sampling for blood gas analysis.
When the low-pressure alarm is activated, the nurse’s most appropriate action would be to
a. assess for cardiac dysrhythmias.
b. rezero the monitoring equipment.
c. check the right hand for pallor.
d. ask the patient about pain.
Correct Answer: A
Rationale: The low-pressure alarm indicates a drop in the patient’s blood pressure which may be caused by cardiac dysrhythmias. There is no
indication to rezero the equipment. Pallor of the right hand would be caused by occlusion of the radial artery by the arterial catheter, not by low
pressure. There is no indication that the patient is experiencing pain.


10. An arterial catheter is inserted in the right brachial artery to monitor a patient’s blood pressure. Which information obtained by the nurse
indicates that a complication of arterial pressure monitoring may be occurring?
a. The Allen test is positive.
b. The mean arterial pressure (MAP) is 102 mm Hg.
c. The dicrotic notch is visible in the waveform.
d. The right hand is numb.
Correct Answer: D
Rationale: Numbness in the right hand suggests that the perfusion distal to the insertion site is decreased. The Allen test is performed before
arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP of 102 is elevated, but this would not be caused by the
arterial line. The dicrotic notch is normally seen on the arterial waveform.

11. When preparing to assist with the insertion of a pulmonary artery catheter, the nurse will anticipate the need to
a. place the patient on a cardiac monitor.
b. administer diuretics before the procedure.
c. auscultate heart sounds during insertion.
d. check cardiac enzymes before insertion.
Correct Answer: A
Rationale: Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor
for these during insertion. Pulmonary artery pressure (PAP) lines are usually inserted to determine fluid status, so diuretics would not be given
until after the PAP line was inserted and the patient’s fluid status was determined. Cardiac enzymes are not needed before the procedure, and
heart sounds are not monitored during insertion.

12. When assisting with insertion of a pulmonary artery (PA) catheter, the nurse identifies that the catheter is correctly placed when the
a. PA waveform is observed on the monitor.
b. monitor shows a typical PAWP tracing.
c. systemic arterial pressure tracing appears on the monitor.
d. catheter has been inserted to the 22-cm marking on the line.
Correct Answer: B
Rationale: The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon
wedges in a distal branch of the pulmonary artery and the PAWP readings are available. After insertion, the balloon is deflated and the PA
waveform will be observed. Systemic arterial pressures are obtained using an arterial line. The length of catheter needed for insertion will vary
with patient size.

13. Which assessment data obtained by the nurse when caring for a patient with a left radial arterial line indicates a need for the nurse to take
action?
a. The flush bag and tubing were last changed 3 days previously.
b. The left hand is cooler than the right hand.
c. The mean arterial pressure (MAP) is 75 mm Hg.
d. The system is delivering only 3 ml of flush solution per hour.
Correct Answer: B
Rationale: The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed
every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6
ml/hour of flush solution.

14. The mixed venous oxygen saturation (SvO2) is decreasing in a patient with hemodynamic monitoring who has severe pancreatitis. The
patient’s PaO2 and cardiac output are stable. To determine the possible cause of the decreased SvO 2, the nurse assesses the patient’s
a. weight.
b. temperature.
c. urinary output.
d. amylase.

Correct Answer: B
Rationale: Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of mixed
venous blood. Information about the patient’s weight, urinary output, and amylase will not help in determining the cause of the patient’s drop in
SvO2.

15. An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. An assessment finding indicating to the nurse
that the goals of treatment with the IABP are being met is a
a. cardiac output (CO) of 2 L/min.
b. stroke volume (SV) of 40 ml/beat.
c. heart rate 110 beats/min.
d. urine output of 100 ml/hr.
Correct Answer: D
Rationale: A urine output of 100 ml/hour indicates good renal perfusion and CO. The CO and SV are lower than normal signify continued
cardiogenic shock. The tachycardia also suggests continued poor SV and inadequate CO.
Cognitive Level: Application Text Reference: pp. 1739, 1749

16. The nurse identifies a collaborative problem of potential for arterial trauma secondary to displacement of the balloon for a patient with an
intraaortic balloon pump (IABP). An appropriate action by the nurse for this problem is to
a. measure the patient’s urinary output every hour.
b. keep the head of the bed elevated 30 to 45 degrees.
c. administer prophylactic heparin as ordered.
d. check the insertion site for bleeding every hour.
Correct Answer: A
Rationale: Displacement of the balloon might occlude the renal arteries, which would decrease renal perfusion and urine output. The other
actions are also appropriate for this patient but would not address the complication of balloon displacement.

17. A patient with severe heart failure has a ventricular assist device (VAD) implanted. When developing the plan of care, the nursing actions
should include
a. teaching the patient the reason for continuous bed rest.
b. preparing the patient to have the VAD in place permanently.
c. monitoring the surgical incision for signs of infection.
d. administration of immunosuppressive medications.
Correct Answer: C
Rationale: The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent
monitoring. Patient’s with VADs are able to have some mobility and may not be on bed rest. A VAD is a bridge to transplantation, not a
permanent device. Immunosuppression is not necessary for nonbiologic devices like the VAD.

18. A patient is admitted to the emergency department comatose and apneic with suspected head and neck injuries after falling from a roof.
Which equipment will the nurse anticipate needing for emergency airway maintenance?
a. Nasal endotracheal (ET) tube
b. Oral ET tube
c. Tracheostomy tube
d. Oropharyngeal airway
Correct Answer: A
Rationale: Nasal ETs are indicated when head and neck injury is suspected to avoid further trauma. Oral ETs are used most commonly in an
emergency but not when there is head/neck trauma. Tracheostomy placement is done when long-term artificial airways are needed.
Oropharyngeal airways do not permit mechanical ventilation, which will be needed for this patient.


19. To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action for the nurse to take is
a. use an end-tidal CO2 monitor to check for placement in the trachea.
b. auscultate for the presence of bilateral breath sounds.
c. obtain a portable chest radiograph to check tube placement.
d. observe the chest for symmetrical movement with ventilation.
Correct Answer: A
Rationale: End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds
and checking chest expansion are also used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is
done after the tube is secured.

20. To inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse
a. uses the minimal occluding volume technique by inflating the cuff with 10 ml of air.
b. injects air into the cuff until a manometer indicates a pressure of 15 mm Hg.
c. injects air into the cuff until no leak is heard at the peak inspiratory pressure.
d. inflates the cuff until the pilot balloon cannot be easily compressed with the fingers.
Correct Answer: C
Rationale: The minimal occluding volume technique involves injecting air into the cuff until no air leak is present at the peak inspiratory
pressure. The volume to inflate the cuff varies with the ET and the patient’s size. Cuff pressure should be maintained at 20 to 25 mm Hg. An
accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.

21. When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). The first intervention by the
nurse is to
a. position the patient in a left lateral position.
b. call the health care provider immediately to reinsert the tube.
c. activate the hospital’s rapid response team.
d. manually ventilate the patient with 100% oxygen.
Correct Answer: D
Rationale: The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Positioning the patient
in an upright position would help maintain the airway. The nurse should stay with the patient and ask someone else to call the health care
provider and the rapid response team.

22. While suctioning a patient with an endotracheal tube (ET), the nurse notes the occurrence of premature ventricular contractions (PVCs) on
the patient’s cardiac monitor. The most appropriate action by the nurse upon this finding is to
a. lower the suction pressure to 80 mm Hg.
b. ventilate the patient with 100% oxygen with a bag-valve mask.
c. notify the health care provider of the need for antidysrhythmic medications.
d. explain that occasional PVCs are expected.
Correct Answer: B
Rationale: Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation, and the nurse should stop
suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without
improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic therapy unless they recur when the
patient is well oxygenated.

23. Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for
suctioning?
a. The patient has not been suctioned for the last 6 hours.
b. The lungs have occasional audible expiratory wheezes.
c. The respiratory rate is 32 breaths/minute.

d. The pulse oximeter shows an SpO2 of 95%.
Correct Answer: C
Rationale: The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is
done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway
clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An SpO 2 of 95% is acceptable and does not suggest that
immediate suctioning is needed.

24. A patient with an oral endotracheal tube (ET) has a nursing diagnosis of risk for aspiration related to the presence of an artificial airway.
The most appropriate nursing intervention for the patient is to
a. maintain cuff pressure at minimal occluding volume to prevent gastric secretions from entering the trachea.
b. perform oral suctioning frequently and before cuff deflation.
c. remove the bite block and perform oral hygiene every 2 hours.
d. use chest physiotherapy to move secretions to large airways where they can be suctioned.
Correct Answer: B
Rationale: Performing oral suctioning frequently and especially before cuff deflation decreases the risk for secretions accumulating above the ET
cuff and moving past the cuff into the lungs. Even when the cuff is at minimal occluding volume, it cannot totally prevent oral or gastric
secretions from leaking past the cuff. Although the patient needs frequent oral care, oral care will not decrease the risk for aspiration. Chest
physiotherapy may be included in the patient’s care but will not decrease the risk for aspiration.

25. The nurse notes that a patient’s endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears
anxious and restless. Which action should the nurse take first?
a. Notify the patient’s health care provider.
b. Listen to the patient’s lungs.
c. Bag the patient at an FIO2 of 100%.
d. Offer reassurance to the patient.
Correct Answer: B
Rationale: The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral
breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and
correction of tube malposition are the most critical action.

26. The nurse develops the diagnosis of ineffective airway clearance related to thick respiratory secretions for a patient with respiratory failure
who is receiving mechanical ventilation. Which intervention will be most effective in resolving this problem?
a. Increase the amount of water in the patient’s enteral feedings.
b. Suction the patient more frequently.
c. Instill 5 ml of sterile saline into the ET before suctioning.
d. Turn the patient every 2 hours.
Correct Answer: A
Rationale: Because the patient’s secretions are thick, better hydration is indicated. Suctioning more frequently will increase the incidence of
mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may
decrease the SpO2. Turning the patient is appropriate but will not decrease the thickness of secretions.

27. The charge nurse evaluates the care that a new RN staff member provides to a patient receiving mechanical ventilation. Which action by the
new RN indicates the need for more education?
a. The RN turns the FIO2 up to 100% before suctioning.
b. The RN asks for assistance to turn the patient to the prone position.
c. The RN secures a bite block in place using adhesive tape.
d. The RN positions the patient with the head of bed at 10 degrees.
Correct Answer: D

Rationale: The head of the patient’s bed should be positioned at 30 to 45 degrees to prevent ventilator-acquired pneumonia. The other actions by
the new RN are appropriate.

28. A patient with chronic obstructive pulmonary disease (COPD) is in acute respiratory failure and has been placed on mechanical ventilation.
Four hours after mechanical ventilation is initiated, the patient’s ABG results include a pH of 7.50, PaO 2 of 80 mm Hg, PaCO2 of 29 mm
Hg, and HCO3– of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to
a. increase the FIO2.
b. increase the tidal volume (VT).
c. decrease the respiratory rate.
d. leave the ventilator on the current settings.
Correct Answer: C
Rationale: The patient’s PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient
with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes.
Cognitive Level: Analysis Text Reference: p. 1764

29. A patient who has respiratory failure and is receiving mechanical ventilation has a nursing diagnosis of risk for injury related to asynchrony
with the ventilator secondary to anxiety. The nurse’s first action should be to
a. verbally coach the patient to breathe with the ventilator.
b. sedate the patient with the ordered PRN lorazepam (Ativan).
c. ventilate the patient with a manual resuscitation bag.
d. increase the rate for the ordered propofol (Diprivan) infusion.
Correct Answer: A
Rationale: The initial response by the nurse should be to try to decrease the patient’s anxiety because anxiety is the major contributing factor
placing the patient at risk for injury. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient’s anxiety.

30. A patient with acute respiratory failure is receiving assist-control mechanical ventilation with peak end-expiratory pressure (PEEP) of 10
cm H2O and has an arterial line and pulmonary artery catheter in place. Which information indicates that a change in the ventilator settings
may be required?
a. The pulmonary artery pressure (PAP) is decreased.
b. The arterial line shows a blood pressure of 90/46.
c. The pulmonary artery wedge pressure (PAWP) is increased.
d. The cardiac monitor shows a heart rate of 58 beats/min.
Correct Answer: B
Rationale: The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and cardiac
output (CO). The other assessment data would not be caused by mechanical ventilation.

31. Which action by a new RN working in the ICU indicates that the education regarding care of the patient receiving manual ventilation with
10 cm of PEEP has been effective?
a. The RN plans to suction the patient every 2 hours.
b. The RN tapes connection between the ventilator tubing and the ET.
c. The RN uses a closed-suction technique to suction the patient.
d. The RN changes the ventilator circuit tubing routinely every 24 hours.
Correct Answer: C
Rationale: The closed-suction technique is suggested when patients require high levels of PEEP to prevent the loss of PEEP that occurs when
disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment
data indicate the need for suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the tubing to
swivel in response to patient repositioning. Ventilator tubing changes increase the risk for VAP and are not indicated routinely.

Nursing Process: Implementation

32. When the nurse is weaning a patient who has COPD from mechanical ventilation, which patient assessment indicates that the weaning
protocol should be discontinued?
a. The patient heart rate is 98 beats/min.
b. The patient’s spontaneous tidal volume is 500 ml.
c. The patient’s oxygen saturation is 91%.
d. The patient respiratory rate is 32 breaths/min.
Correct Answer: D
Rationale: Tachypnea is a sign that the patient’s work of breathing is too high to allow weaning to proceed. The patient’s heart rate is within
normal limits, although the nurse should continue to monitor it. An oxygen saturation of 91% is acceptable for a patient with COPD. A
spontaneous tidal volume of 500 ml is within the acceptable range.

33. A patient with a subarachnoid hemorrhage is intubated and placed on a mechanical volume-cycled ventilator in the spontaneous intermittent
mandatory volume (SIMV) mode, FIO2 40%, rate 14, VT 700, with 10 cm of PEEP. When monitoring the patient, the nurse will need to
notify the health care provider if the patient develops
a. respiratory rate of 18 breaths/min.
b. O2 saturation of 94%.
c. increased jugular vein distension (JVD).
d. greenish-brown nasogastric tube drainage.
Correct Answer: C
Rationale: Increases in JVD in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the
PEEP is too high for this patient. A respiratory rate of 18, O2 saturation of 94%, and greenish-brown nasogastric tube drainage are normal.

34. The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment information
indicates that the infusion rate may be too high?
a. Heart rate is 58 beats/min.
b. Mean arterial pressure is 55 mm Hg.
c. Systemic vascular resistance (SVR) is elevated.
d. Pulmonary artery wedge pressure (PAWP) is low.
Correct Answer: C
Rationale: Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of the heart and decrease
peripheral perfusion. Bradycardia, hypotension, and low PAWP would not indicate a need for a decrease in the rate of norepinephrine
(Levophed).

35. When caring for the patient with a pulmonary artery pressure catheter, the nurse notes that the PA wave form indicates that the catheter is in
the wedged position. Which action should the nurse take?
a. Zero balance the transducer.
b. Inflate the PA balloon.
c. Notify the health care provider.
d. Change the flush system.
Correct Answer: C
Rationale: When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary
infarction. A health care provider or specially trained nurse should be called to reposition the catheter, not the ICU nurse. Inflation of the balloon
would further occlude blood flow and might rupture the pulmonary artery. Zeroing the transducer and changing the flush system will not correct
the problem with the catheter position.

36. Which action by a new RN who is caring for a patient with an intraaortic balloon catheter inserted in the left femoral artery will require
immediate intervention by the ICU charge nurse?

a. The new RN checks the patient’s pedal pulses every 30 minutes.
b. The new RN elevates the head of the patient’s bed to 90 degrees.
c. The new RN turns the patient onto the left side.
d. The new RN has the patient take deep breaths.
Correct Answer: B
Rationale: The head of the bed should not be elevated more than 45 degrees to avoid kinking the IABP catheter. The other nursing actions are
appropriate when caring for a patient with an IABP.

37. While assessing a patient with a central venous catheter in place in the left subclavian vein, the nurse notes the catheter insertion site is red
and tender and the patient’s temperature is 101.8° F. The nurse will plan to
a. change the flush system and monitor the site.
b. administer analgesics and antibiotics.
c. discontinue the catheter and culture the tip.
d. check the site frequently for any swelling.
Correct Answer: C
Rationale: The information indicates that the patient has a local and systemic infection caused by the catheter and the catheter should be
discontinued. Changing the flush system, administration of analgesics, and continued monitoring will not help prevent or treat the infection.
Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis.

38. An elderly patient who has been in the ICU for a week is preparing for transfer to the step-down unit when the nurse notices that the patient
has new-onset restlessness and confusion. The patient’s physiologic status is stable and otherwise unchanged. The nurse should
a. inform the receiving nurse and proceed with the transfer.
b. notify the health care provider and postpone the transfer.
c. administer PRN lorazepam (Ativan) and proceed with the transfer.
d. obtain an order to restrain the patient and proceed with the transfer.
Correct Answer: A
Rationale: The patient’s history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the
ICU environment, and informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the
delirium. Benzodiazepines and restraints contribute to delirium and agitation.

Test Bank
Chapter 67 : Nursing Management: Shock, Systemic Inflammatory

Response Syndrome, and Multiple Organ Dysfunction Syndrome
MULTIPLE CHOICE
1. A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
a. check the blood pressure.
b. obtain an oxygen saturation.
c. attach a cardiac monitor.
d. check level of consciousness.
Correct Answer: B
Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments
should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.


2. A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5
mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready;
respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands
and feet. The nurse recognizes that the patient is experiencing the
a. progressive stage of septic shock.
b. compensatory stage of diabetic shock.
c. refractory stage of cardiogenic shock.
d. progressive stage of hypovolemic shock.
Correct Answer: D
Rationale: The patient’s history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with hypovolemia, and the
symptoms are most consistent with the progressive stage of shock. The patient’s temperature of 97° F is inconsistent with septic shock. The
history is inconsistent with a diagnosis of cardiogenic shock, and the patient’s neurologic status is not consistent with refractory shock.
Cognitive Level: Analysis Text Reference: pp. 1776, 1781

3. A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism
that leads to altered urinary output is
a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries.
b. stimulation of cardiac -adrenergic receptors, leading to increased cardiac output.
c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.
d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.
Correct Answer: C
Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the
renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve
urine output. During shock, fluid leaks from the intravascular space into the interstitial space.

4. While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding
a. cold, mottled extremities.
b. restlessness and apprehension.
c. a heart rate of 120 and cool, clammy skin.
d. systolic BP less than 90 mm Hg.
Correct Answer: B
Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin,
and a systolic BP less than 90 are associated with the progressive and refractory stages.

5. When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate
administration of large volumes of crystalloids when the
a. cardiac output is increased and the central venous pressure (CVP) is low.
b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low.
c. heart rate is decreased, and the systemic vascular resistance is low.
d. cardiac output is decreased and the PAWP is high.
Correct Answer: A
Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that
the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular
resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.
Cognitive Level: Application Text Reference: pp. 1774, 1783-1786

6. A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All
of these orders are written. Which one will the nurse act on first?
a. Insert two 14-gauge IV catheters.
b. Administer oxygen at 100% per non-rebreather mask.
c. Place the patient on continuous cardiac monitor.
d. Draw blood to type and crossmatch for transfusions.

Test Bank 69-17
Correct Answer: B
Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV
catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have
been implemented.

7. A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be
experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of
a. cool, clammy skin.
b. shortness of breath.
c. heart rate of 48 beats/min
d. BP of 82/40 mm Hg.
Correct Answer: C
Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed
parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.

8. The nurse caring for a patient in shock notifies the health care provider of the patient’s deteriorating status when the patient’s ABG results
include
a. pH 7.48, PaCO2 33 mm Hg.
b. pH 7.33, PaCO2 30 mm Hg.
c. pH 7.41, PaCO2 50 mm Hg.
d. pH 7.38, PaCO2 45 mm Hg.
Correct Answer: B
Rationale: The patient’s low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the
progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning “pH 7.48” suggest a mild respiratory
alkalosis (consistent with compensated shock). The values in the answer beginning “pH 7.41” suggest compensated respiratory acidosis. The
values in the answer beginning “pH 7.38” are normal.
Cognitive Level: Application Text Reference: pp. 1781-1782, 1793

9. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left-forearm IV. Which assessment
information obtained by the nurse indicates a need for immediate action?
a. The patient has an apical pulse rate of 58 beats/min.
b. The patient’s urine output has been 28 ml over the last hour.
c. The patient’s IV infusion site is cool and pale.
d. The patient has warm, dry skin on the extremities.
Correct Answer: C
Rationale: The coldness and pallor at the infusion site suggest extravasation of the Neo-Synephrine. The nurse should discontinue the IV and, if
possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need
for nursing intervention. A 28-ml 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 indicates that the patient is in early neurogenic shock.
Cognitive Level: Application Text Reference: pp. 1777, 1785, 1789

10. A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates
the administration of
a. nitroglycerine (Tridil).
b. dobutamine (Dobutrex).
c. norepinephrine (Levophed).
d. sodium nitroprusside (Nipride).
Correct Answer: C
Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance
(SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase
stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.

Test Bank 69-18

11. A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action
will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and
multiorgan dysfunction syndrome (MODS)?
a. Administer all medications through the patient’s indwelling central line.
b. Place the patient in a private room.
c. Restrict the patient to foods that have been well-cooked or processed.
d. Insert a nasogastric (NG) tube for enteral feeding.
Correct Answer: B
Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the
exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection
and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease
oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the
patient’s nausea and vomiting.

12. All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who develops severe respiratory
distress and faintness. Which one will the nurse administer first?
a. Epinephrine (Adrenalin)
b. Normal saline infusion
c. Dexamethasone (Decadron)
d. Diphenhydramine (Benadryl)
Correct Answer: A
Rationale: 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 administered.

13. A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30.
Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate
a. administration of furosemide (Lasix) IV.
b. titration of an epinephrine (Adrenalin) drip.
c. administration of a normal saline bolus.
d. assisting with endotracheal intubation.
Correct Answer: A
Rationale: 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 myocardial oxygen demand and might extend the MI. The PAWP is already elevated, so normal
saline boluses would be contraindicated. There is no indication that the patient requires endotracheal intubation.

14. The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle
accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient’s arrival, the nurse will obtain
a. a liter of lactated Ringer’s solution.
b. 500 ml of 5% albumin.
c. two 14-gauge IV catheters.
d. a retention catheter.
Correct Answer: C
Rationale: 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 had been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, it is generally
accepted that crystalloids should be used as the initial therapy for fluid resuscitation. A catheter would likely be ordered, but in the 1 minute that
the nurse has to obtain supplies, the IV catheters would take priority.

Test Bank 69-19

15. The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient’s
a. urine output is 40 ml over the last hour.
b. hemoglobin is within normal limits.
c. CVP has decreased.
d. mean arterial pressure (MAP) is 65 mm Hg.
Correct Answer: A
Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful.
The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving
blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue
perfusion is adequate.

16. The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a
need for a change in therapy?
a. The patient is restless and anxious.
b. The patient has a heart rate of 134.
c. The patient has hypotonic bowel sounds.
d. The patient has a temperature of 94.1° F.
Correct Answer: D
Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated
shock.

17. Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the drug, the nurse ensures that
the
a. patient’s heart rate is less than 100.
b. patient has received adequate fluid replacement.
c. patient’s urine output is within normal range.
d. patient is not receiving other sympathomimetic drugs.
Correct Answer: B
Rationale: If vasoconstrictors are given in a hypovolemic patient, the peripheral vasoconstriction will further decrease tissue perfusion. A patient
with hypovolemia is likely to have a heart rate greater than 100 and a low urine output, so these values are not contraindications to
vasoconstrictor therapy. Patients may receive other sympathomimetic drugs concurrently with Levophed.

18. When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and nitroglycerin (Tridil) infusions, the
best evidence that the medications are effective is that the
a. systolic BP increases to greater than 100 mm Hg.
b. cardiac monitor shows sinus rhythm at 96 beats/min.
c. PAWP drops to normal range.
d. troponin and creatine kinase levels decrease.
Correct Answer: C
Rationale: Because PAWP is increased in cardiogenic shock as a result of the increase in volume and pressure in the left ventricle, normalization
of PAWP is the best indicator of patient improvement. The changes in BP and heart rate could occur with dobutamine infusion even if patient
tissue perfusion was not improved. Troponin and creatine kinase (CK) levels are indicators of cardiac cellular death and are not used as indicators
of improved tissue perfusion.

19. While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg
when the head of the patient’s bed is elevated to 75 degrees. This finding indicates a need for

Test Bank 69-20
a. additional fluid replacement.

b. antibiotic administration.
c. infusion of a sympathomimetic drug.
d. administration of increased oxygen.
Correct Answer: A
Rationale: A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions. There are no data to
suggest that antibiotics, sympathomimetics, or additional oxygen are needed.

20. The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to
a. arrange for the hospital pastoral care staff to visit the patient.
b. ask the health care provider to prescribe a sedative drug for the patient.
c. leave the patient alone with family members whenever possible.
d. place the patient’s call bell where it can be easily reached.
Correct Answer: D
Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff should be asked to visit
only after checking with the patient to determine whether this is desired. Providing time for family to spend with the patient is appropriate, but
patients and family should not feel that the nurse is unavailable. Sedative administration is helpful but does not as directly address the patient’s
anxiety about dying.

Nursing Process: Planning NCLEX: Psychosocial Integrity
21. A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative
hypovolemia is
a. urine output of 0.5 ml/kg/hr.
b. decreased peripheral edema.
c. decreased CVP.
d. oxygen saturation 90% or more.
Correct Answer: A
Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may
continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased
central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation
of 90% will not necessarily indicate that cardiac output has improved.

22. A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood
glucose 246 mg/dl. Which order will the nurse accomplish first?
a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl.
b. Give normal saline IV at 500 ml/hr.
c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg.
d. Infuse drotrecogin- (Xigris) 24 mcg/kg.
Correct Answer: B
Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The
other actions are also appropriate and should be initiated quickly as well.

23. A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which
information obtained by the nurse indicates that the patient is still in the compensatory stage of shock?
a. The cardiac output is elevated.
b. The central venous pressure (CVP) is increased.
c. The systemic vascular resistance (SVR) is high.
d. The PAWP is high.
Correct Answer: A

Test Bank 69-21
Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had
developed progressive or refractory septic shock.

24. When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the
diagnosis of MODS?
a. The patient has crackles throughout both lung fields.
b. The patient complains of 8/10 crushing chest pain.
c. The patient has an elevated ammonia level and confusion.
d. The patient has cool extremities and weak pedal pulses.
Correct Answer: C
Rationale: The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure. The crackles, chest pain, and cool
extremities are all consistent with cardiogenic shock and do not indicate that there are failures in other major organ systems.

25. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for
the nurse to make are
a. stool guaiac and bowel sounds.
b. lung sounds and oxygenation status.
c. serum creatinine and urinary output.
d. serum bilirubin levels and skin color.
Correct Answer: B
Rationale: The respiratory system is usually the system to show the signs of MODS because of the direct effect of inflammatory mediators on
the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.

26. An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes
a. respiratory rate of 10 breaths/min.
b. fixed urine specific gravity at 1.010.
c. MAP of 55 mm Hg.
d. 360-ml urine output in 8 hours.
Correct Answer: B
Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular necrosis. With MODS,
the patient’s respiratory rate would initially increase. The MAP of 55 shows continued shock, but not necessarily progression to MODS. A 360-
ml urine output over 8 hours indicates adequate renal perfusion.

27. When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the
nurse?
a. BP 88/56 mm Hg
b. Apical pulse 110 beats/min
c. Urine output 15 ml for 2 hours
d. Arterial oxygen saturation 90%
Correct Answer: C
Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine
output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of
shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.


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Lewis: Medical-Surgical Nursing, 7th Edition

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