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.
1a
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.
1b
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.

2a
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.
2b
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.
3a
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.
3b
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.
4a
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.
4b
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.
5a
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.
5b
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).
6a
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.
6b
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.
7a
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. 7b
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.
8a
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.
8b
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.
9a
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.
9b
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.
10a
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.
10b
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.
11a
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.
11b
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.
12a
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.
12b
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.
13a
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. 13b
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.
14a
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.
14b
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.
15a
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.
15b
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.
16a
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.
16b
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%
17a
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.
17b
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.
18a
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. 18b
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.
19a
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. 19b