Nursing Management: Shock & MODS
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1. 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.
2. 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: 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.
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.
3. 4. While caring for a Correct Answer: B
seriously ill patient, Rationale: Restlessness and
the nurse apprehension are typical during the
determines that the compensatory stage of shock. Cold,
patient may be in mottled extremities, cool and clammy
the compensatory skin, and a systolic BP less than 90 are
stage of shock on associated with the progressive and
finding refractory stages.
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.
4. 5. When assessing Correct Answer: A
the hemodynamic Rationale: A high cardiac output and
information for a low CVP suggest septic shock, and
newly admitted massive fluid replacement is indicated.
patient in shock of Increased PAWP indicates that the
unknown etiology, patient has excessive fluid volume
the nurse will (and suggests cardiogenic shock), and
anticipate diuresis is indicated. Bradycardia and a
administration of low systemic vascular resistance (SVR)
large volumes of suggest neurogenic shock, and fluids
crystalloids when should be infused cautiously.
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.
5. 6. A patient who has Correct Answer: B 7. 8. The nurse Correct Answer: B
been involved in a Rationale: The first priority in the caring for a Rationale: The patient's low pH in spite of
motor-vehicle crash is initial management of shock is patient in shock a respiratory alkalosis indicates that the
admitted to the ED with maintenance of the airway and notifies the patient has severe metabolic acidosis and
cool, clammy skin, ventilation. Cardiac monitoring, health care is experiencing the progressive stage of
tachycardia, and insertion of IV catheters, and provider of the shock; rapid changes in therapy are
hypotension. All of obtaining blood for transfusions patient's needed. The values in the answer
these orders are written. should also be rapidly deteriorating beginning "pH 7.48" suggest a mild
Which one will the nurse accomplished, but only after status when the respiratory alkalosis (consistent with
act on first? actions to maximize oxygen patient's ABG compensated shock). The values in the
a. Insert two 14-gauge IV delivery have been implemented. results include answer beginning "pH 7.41" suggest
catheters. a. pH 7.48, compensated respiratory acidosis. The
b. Administer oxygen at PaCO2 33 mm values in the answer beginning "pH 7.38"
100% per non-rebreather Hg. are normal.
mask. b. pH 7.33,
c. Place the patient on PaCO2 30 mm
continuous cardiac Hg.
monitor. c. pH 7.41, PaCO2
d. Draw blood to type 50 mm Hg.
and crossmatch for d. pH 7.38,
transfusions. PaCO2 45 mm
Hg.
6. 7. A patient with massive Correct Answer: C
trauma and possible Rationale: The normal 8. 9. The patient Correct Answer: C
spinal cord injury is sympathetic response to with neurogenic Rationale: The coldness and pallor at the
admitted to the ED. The shock/hypotension is an increase shock is infusion site suggest extravasation of the
nurse suspects that the in heart rate. The presence of receiving a Neo-Synephrine. The nurse should
patient may be bradycardia suggests unopposed phenylephrine discontinue the IV and, if possible, infuse
experiencing neurogenic parasympathetic function, as (Neo- the medication into a central line. An
shock in addition to occurs in neurogenic shock. The Synephrine) apical pulse of 58 is typical for
hypovolemic shock, other symptoms are consistent infusion through neurogenic shock but does not indicate an
based on the finding of with hypovolemic shock. a left-forearm immediate need for nursing intervention. A
a. cool, clammy skin. IV. Which 28-ml output over 1 hour would require
b. shortness of breath. assessment the nurse to monitor the output over the
c. heart rate of 48 information next hour, but an immediate change in
beats/min obtained by the therapy is not indicated. Warm, dry skin
d. BP of 82/40 mm Hg. nurse indicates a indicates that the patient is in early
need for neurogenic shock.
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.
9. 10. A patient in Correct Answer: C 11. 12. All of these Correct Answer: A
septic shock has not Rationale: When fluid resuscitation is collaborative Rationale: Epinephrine rapidly
responded to fluid unsuccessful, administration of interventions are causes peripheral vasoconstriction,
resuscitation, as vasopressor drugs is used to increase ordered by the health dilates the bronchi, and blocks the
evidenced by a the systemic vascular resistance (SVR) care provider for a effects of histamine and reverses
decreasing BP and and improve tissue perfusion. patient stung by a bee the vasodilation,
cardiac output. The Nitroglycerin would decrease the who develops severe bronchoconstriction, and histamine
nurse anticipates the preload and further drop cardiac respiratory distress release that cause the symptoms of
administration of output and BP. Dobutamine will and faintness. Which anaphylaxis. The other interventions
a. nitroglycerine increase stroke volume, but it would one will the nurse are also appropriate but would not
(Tridil). also further decrease SVR. administer first? be the first ones administered.
b. dobutamine Nitroprusside is an arterial a. Epinephrine
(Dobutrex). vasodilator and would further (Adrenalin)
c. norepinephrine decrease SVR. b. Normal saline
(Levophed). infusion
d. sodium c. Dexamethasone
nitroprusside (Decadron)
(Nipride). d. Diphenhydramine
(Benadryl)
10. 11. A patient who is Correct Answer: B
receiving Rationale: The patient who has 12. 13. A patient with a Correct Answer: A
chemotherapy is received chemotherapy is immune myocardial infarction Rationale: The PAWP indicates that
admitted to the compromised, and placing the patient (MI) and cardiogenic the patient's preload is elevated and
hospital with acute in a private room will decrease the shock has the furosemide is indicated to reduce
dehydration caused exposure to other patients and reduce following vital signs: the preload and improve cardiac
by nausea and infection/sepsis risk. Administration of BP 86/50, pulse 126, output. Epinephrine would further
vomiting. Which medications through the central line respirations 30. increase myocardial oxygen
action will the nurse increases the risk for infection and Hemodynamic demand and might extend the MI.
include in the plan sepsis. There is no indication that the monitoring reveals an The PAWP is already elevated, so
of care to best patient is neutropenic, and restricting elevated PAWP and normal saline boluses would be
prevent the the patient to cooked and processed decreased cardiac contraindicated. There is no
development of foods is likely to decrease oral intake output. The nurse will indication that the patient requires
shock, systemic further and cause further malnutrition, anticipate endotracheal intubation.
inflammatory a risk factor for sepsis and shock. a. administration of
response syndrome Insertion of an NG tube is invasive furosemide (Lasix) IV.
(SIRS), and and will not decrease the patient's b. titration of an
multiorgan nausea and vomiting. epinephrine
dysfunction (Adrenalin) drip.
syndrome (MODS)? c. administration of a
a. Administer all normal saline bolus.
medications through d. assisting with
the patient's endotracheal
indwelling central intubation.
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.
13. 14. The triage Correct Answer: C 15. 16. The nurse is Correct Answer: D
nurse receives a Rationale: A patient with multiple trauma caring for a Rationale: Hypothermia is an indication
call from a may require fluid resuscitation to prevent patient admitted that the patient is in the progressive
community or treat hypovolemic shock, so the nurse with a urinary stage of shock. The other data are
member who is will anticipate the need for 2 large bore tract infection and consistent with compensated shock.
driving an IV lines to administer normal saline. sepsis. Which
unconscious Lactated Ringer's solution should be information
friend with used cautiously and will not be ordered obtained in the
multiple injuries until the patient had been assessed for assessment
after a possible liver abnormalities. Although indicates a need
motorcycle colloids may sometimes be used for for a change in
accident to the volume expansion, it is generally therapy?
hospital. The accepted that crystalloids should be a. The patient is
caller states that used as the initial therapy for fluid restless and
they will be resuscitation. A catheter would likely be anxious.
arriving in 1 ordered, but in the 1 minute that the nurse b. The patient has
minute. In has to obtain supplies, the IV catheters a heart rate of
preparation for would take priority. 134.
the patient's c. The patient has
arrival, the nurse hypotonic bowel
will obtain sounds.
a. a liter of d. The patient has
lactated Ringer's a temperature of
solution. 94.1° F.
b. 500 ml of 5%
16. 17. Norepinephrine Correct Answer: B
albumin.
(Levophed) has Rationale: If vasoconstrictors are given
c. two 14-gauge
been ordered for in a hypovolemic patient, the peripheral
IV catheters.
the patient in vasoconstriction will further decrease
d. a retention
hypovolemic tissue perfusion. A patient with
catheter.
shock. Before hypovolemia is likely to have a heart
14. 15. The nurse Correct Answer: A administering the rate greater than 100 and a low urine
evaluates that Rationale: Assessment of end-organ drug, the nurse output, so these values are not
fluid resuscitation perfusion, such as an adequate urine ensures that the contraindications to vasoconstrictor
for a 70 kg output, is the best indicator that fluid a. patient's heart therapy. Patients may receive other
patient in shock is resuscitation has been successful. The rate is less than sympathomimetic drugs concurrently
effective on hemoglobin level is not useful in 100. with Levophed.
finding that the determining whether fluid administration b. patient has
patient's has been effective unless the patient is received
a. urine output is bleeding and receiving blood. A adequate fluid
40 ml over the decrease in CVP indicates that more fluid replacement.
last hour. is needed. The MAP is at the low normal c. patient's urine
b. hemoglobin is range, but does not clearly indicate that output is within
within normal tissue perfusion is adequate. normal range.
limits. d. patient is not
c. CVP has receiving other
decreased. sympathomimetic
d. mean arterial drugs.
pressure (MAP) is
65 mm Hg.
17. 18. When the nurse Correct Answer: C 19. 20. The best Correct Answer: D
is caring for a Rationale: Because PAWP is increased nursing Rationale: The patient who is fearful should
patient in in cardiogenic shock as a result of the intervention feel that the nurse is immediately available if
cardiogenic shock increase in volume and pressure in the for a patient needed. Pastoral care staff should be asked to
who is receiving left ventricle, normalization of PAWP in shock who visit only after checking with the patient to
dobutamine is the best indicator of patient has a nursing determine whether this is desired. Providing
(Dobutrex) and improvement. The changes in BP and diagnosis of time for family to spend with the patient is
nitroglycerin (Tridil) heart rate could occur with fear related appropriate, but patients and family should
infusions, the best dobutamine infusion even if patient to perceived not feel that the nurse is unavailable. Sedative
evidence that the tissue perfusion was not improved. threat of administration is helpful but does not as
medications are Troponin and creatine kinase (CK) death is to directly address the patient's anxiety about
effective is that the levels are indicators of cardiac a. arrange dying.
a. systolic BP cellular death and are not used as for the
increases to greater indicators of improved tissue hospital
than 100 mm Hg. perfusion. pastoral care
b. cardiac monitor staff to visit
shows sinus rhythm the patient.
at 96 beats/min. b. ask the
c. PAWP drops to health care
normal range. provider to
d. troponin and prescribe a
creatine kinase sedative
levels decrease. drug for the
patient.
18. 19. While assessing Correct Answer: A
c. leave the
a patient in shock Rationale: A postural drop in BP is an
patient alone
who has an arterial indication of volume depletion and
with family
line in place, the suggests the need for additional fluid
members
nurse notes a drop infusions. There are no data to suggest
whenever
in the systolic BP that antibiotics, sympathomimetics, or
possible.
from 92 mm Hg to additional oxygen are needed.
d. place the
76 mm Hg when the
patient's call
head of the
bell where it
patient's bed is
can be easily
elevated to 75
reached.
degrees. This
finding indicates a
need for
a. additional fluid
replacement.
b. antibiotic
administration.
c. infusion of a
sympathomimetic
drug.
d. administration of
increased oxygen.
20. 21. A patient Correct Answer: A 22. 23. A patient in Correct Answer: A
outcome that is Rationale: A urine output of 0.5 ml/kg/hr compensated septic shock Rationale: In the early stages
appropriate for indicates adequate renal perfusion, which has hemodynamic of septic shock, the cardiac
the patient in is a good indicator of cardiac output. The monitoring with a output is high. The other
shock who has a patient may continue to have peripheral pulmonary artery catheter hemodynamic changes would
nursing edema because fluid infusions may be and an arterial catheter. indicate that the patient had
diagnosis of needed despite third-spacing of fluids in Which information developed progressive or
decreased relative hypovolemia. Decreased central obtained by the nurse refractory septic shock.
cardiac output venous pressure (CVP) for a patient with indicates that the patient is
related to relative hypovolemia indicates that still in the compensatory
relative additional fluid infusion is necessary. An stage of shock?
hypovolemia is oxygen saturation of 90% will not a. The cardiac output is
a. urine output necessarily indicate that cardiac output elevated.
of 0.5 ml/kg/hr. has improved. b. The central venous
b. decreased pressure (CVP) is
peripheral increased.
edema. c. The systemic vascular
c. decreased resistance (SVR) is high.
CVP. d. The PAWP is high.
d. oxygen
23. 24. When caring for a Correct Answer: C
saturation 90%
patient with cardiogenic Rationale: The elevated
or more.
shock and possible MODS, ammonia level and confusion
21. 22. A patient Correct Answer: B which information obtained suggest liver failure in addition
who has just Rationale: Because of the low systemic by the nurse will help to the cardiac failure. The
been admitted vascular resistance (SVR) associated with confirm the diagnosis of crackles, chest pain, and cool
with septic shock septic shock, fluid resuscitation is the MODS? extremities are all consistent
has a BP of initial therapy. The other actions are also a. The patient has crackles with cardiogenic shock and do
70/46, pulse 136, appropriate and should be initiated throughout both lung not indicate that there are
respirations 32, quickly as well. fields. failures in other major organ
temperature b. The patient complains of systems.
104.0° F, and 8/10 crushing chest pain.
blood glucose c. The patient has an
246 mg/dl. elevated ammonia level
Which order will and confusion.
the nurse d. The patient has cool
accomplish first? extremities and weak pedal
a. Start insulin pulses.
drip to maintain
24. 25. To monitor a patient Correct Answer: B
blood glucose at
with severe acute Rationale: The respiratory
110 to 150 mg/dl.
pancreatitis for the early system is usually the system to
b. Give normal
organ damage associated show the signs of MODS
saline IV at 500
with MODS, the most because of the direct effect of
ml/hr.
important assessments for inflammatory mediators on the
c. Titrate
the nurse to make are pulmonary system. The other
norepinephrine
a. stool guaiac and bowel assessment data are also
(Levophed) to
sounds. important to collect, but they
keep MAP at 65
b. lung sounds and will not indicate the
to 70 mm Hg.
oxygenation status. development of MODS as
d. Infuse
c. serum creatinine and early.
drotrecogin-
urinary output.
(Xigris) 24
d. serum bilirubin levels
mcg/kg.
and skin color.
25. 26. An Correct Answer: B 27. A patient is treated 1.Correct Answer: B
assessment Rationale: A fixed urine specific gravity in the emergency Rationale: The initial actions of the
finding points to an inability of the kidney to department (ED) for nurse are focused on the ABCs, and
indicating to concentrate urine caused by acute tubular shock of unknown assessing the airway and ventilation is
the nurse that a necrosis. With MODS, the patient's etiology. The first necessary. The other assessments
70-kg patient respiratory rate would initially increase. action by the nurse should be accomplished as rapidly as
in septic shock The MAP of 55 shows continued shock, but should be to possible after the oxygen saturation is
is progressing not necessarily progression to MODS. A a. check the blood determined and addressed.
to MODS 360-ml urine output over 8 hours indicates pressure.
includes adequate renal perfusion. b. obtain an oxygen
a. respiratory saturation.
rate of 10 c. attach a cardiac
breaths/min. monitor.
b. fixed urine d. check level of
specific gravity consciousness.
at 1.010.
c. MAP of 55
mm Hg.
d. 360-ml urine
output in 8
hours.
26. 27. When caring Correct Answer: C
for a patient Rationale: The best data for assessing the
who has just adequacy of cardiac output are those that
been admitted provide information about end-organ
with septic perfusion such as urine output by the
shock, which of kidneys. The low urine output is an
these indicator that renal tissue perfusion is
assessment inadequate and the patient is in the
data will be of progressive stage of shock. The low BP,
greatest increase in pulse, and low-normal O2
concern to the saturation are more typical of
nurse? compensated septic shock.
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%