Chapter 67 Nursing Management Shock Systemic Inflammatory R
Chapter 67: Nursing Management: Shock, Systemic Inflammatory Response
Syndrome, and Multiple Organ Dysfunction Syndrome
Test Bank
MULTIPLE CHOICE
1. A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The
pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question?
a. Give PRN furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Administer hydrocortisone (Solu-Cortef) 100 mg IV.
d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.
DIF: Cognitive Level: Apply (application)
REF:
1640
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
2. A nurse is caring for a patient with shock of unknown etiology whose hemodynamic
monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure.
Which collaborative intervention ordered by the health care provider should the nurse question? a. Infuse normal saline at 250 mL/hr.
b. Keep head of bed elevated to 30 degrees.
c. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg.
d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A
The patient’s elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the patient.
DIF: Cognitive Level: Apply (application)
REF:
1633
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
3. A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the
emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
a. Inspiratory crackles.
b. Cool, clammy extremities.
c. Apical heart rate 45 beats/min.
d.
Syndrome, and Multiple Organ Dysfunction Syndrome
Test Bank
MULTIPLE CHOICE
1. A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The
pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question?
a. Give PRN furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Administer hydrocortisone (Solu-Cortef) 100 mg IV.
d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.
DIF: Cognitive Level: Apply (application)
REF:
1640
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
2. A nurse is caring for a patient with shock of unknown etiology whose hemodynamic
monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure.
Which collaborative intervention ordered by the health care provider should the nurse question? a. Infuse normal saline at 250 mL/hr.
b. Keep head of bed elevated to 30 degrees.
c. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg.
d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A
The patient’s elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the patient.
DIF: Cognitive Level: Apply (application)
REF:
1633
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
3. A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the
emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
a. Inspiratory crackles.
b. Cool, clammy extremities.
c. Apical heart rate 45 beats/min.
d.