Test bank for introduction to critical care nursing 6th edition by sole

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Test Bank for Introduction to Critical Care Nursing 6th
Edition by Sole
Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Test Bank
MULTIPLE CHOICE

1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse
palpates thready brachial pulses but is unable to auscultate a blood pressure.
What is the best nursing action?
a.

Assess the blood pressure by Doppler.

b.

Estimate the systolic pressure as 60 mm Hg.

c.

Obtain an electronic blood pressure monitor.

d.

Record the blood pressure as “not assessable.”

ANS: A
Auscultated blood pressures in shock may be significantly inaccurate due to
vasoconstriction. If blood pressure is not audible, the approximate value can be

assessed by palpation or ultrasound. If brachial pulses are palpable, the
approximate measure of systolic blood pressure is 80 mm Hg. This action has the
potential to delay further assessment of a compromised patient in shock.




Documenting a blood pressure as not assessable is not appropriate without further
attempts using different modalities.

DIF: Cognitive Level: Application

REF: p. 258

OBJ: Develop an individualized plan of care that includes nursing diagnosis,
expected outcomes, nursing interventions, and rationales.
TOP: Nursing
Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal
saline in a patient with severe sepsis. One hour later, which laboratory result
requires immediate nursing action?
a.

Creatinine 1.0 mg/dL

b.

Lactate 6 mmol/L

c.

Potassium 3.8 mEq/L

d.

Sodium 140 mEq/L

ANS: B
Lactate level has been used as an indicator of decreased oxygen delivery to the cells,
adequacy of resuscitation in shock, and as an outcome predictor. All other listed
values are within normal limits and do not require additional follow-up.




DIF: Cognitive Level: Application

REF: p. 259 | Laboratory Alert

OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

3. The nurse has been administering 0.9% normal saline intravenous fluids as
part of early goal-directed therapy protocols in a patient with severe sepsis.
To evaluate the effectiveness of fluid therapy, which physiological parameters
would be most important for the nurse to assess?
a.

Breath sounds and capillary refill

b.

Blood pressure and oral temperature

c.

Oral temperature and capillary refill

d.

Right atrial pressure and urine output

ANS: D
Early goal-directed therapy includes administration of IV fluids to keep central
venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy
effectiveness can be adequately assessed. Evaluation of breath sounds assists with
determining fluid overload in a patient but does not evaluate the effectiveness of
fluid therapy. Capillary refill provides a quick assessment of the patient’s overall
cardiovascular status, but this assessment is not reliable in a patient who is
hypothermic or has peripheral circulatory problems. Evaluation of oral temperature
does not assess the effectiveness of fluid therapy in patients in shock. Evaluation of
oral temperature does not assess the effectiveness of fluid therapy in patients in




shock. Capillary refill provides a quick assessment of the patient’s overall

cardiovascular status, but this assessment is not reliable in a patient who is
hypothermic or has peripheral circulatory problems.

DIF: Cognitive Level: Application

REF: p. 282

OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

4. A patient is admitted to the critical care unit following coronary artery bypass
surgery. Two hours postoperatively, the nurse assesses the following
information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg;
pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min;
urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best
interpretation by the nurse?
a.

The assessed values are within normal limits.

b.

The patient is at risk for developing cardiogenic shock.

c.

The patient is at risk for developing fluid volume
overload.

d.

The patient is at risk for developing hypovolemic
shock.

ANS: D




Vital signs and hemodynamic values assessed collectively include classic signs and
symptoms of hypovolemia. Both urine output and chest drainage values are high,
contributing to the hypovolemia. Assessed values are not within normal limits.
A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at
risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest
drainage and urine output.

DIF: Cognitive Level: Analysis

REF: p. 270 | Table 11-5

OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk

5. A patient is admitted after collapsing at the end of a summer marathon. She is
lethargic, with a heart rate of 110 beats/min, respiratory rate of 30
breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates
administering which therapeutic intervention?
a.

Human albumin infusion

b.

Hypotonic saline solution

c.

Lactated Ringer’s bolus

d.

Packed red blood cells

ANS: C




The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids,
such as normal saline and lactated Ringer’s solutions, are the priority intervention.
Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid
solutions that are infused when the volume loss is caused by a loss of plasma rather
than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions
rapidly leave the intravascular space, causing interstitial and intracellular edema
and are not used for fluid resuscitation. There is no evidence to support a
transfusion in the given scenario.

DIF: Cognitive Level: Analysis

REF: p. 270 | Table 11-5

OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

6. The nurse is caring for a patient in the early stages of septic shock. The
patient is slightly confused and flushed, with bounding peripheral pulses.
Which hemodynamic values is the nurse most likely to assess?
a.

High pulmonary artery occlusive pressure and high
cardiac output

b.

High systemic vascular resistance and low cardiac
output

c.

Low pulmonary artery occlusive pressure and low
cardiac output

d.

Low systemic vascular resistance and high cardiac
output

ANS: D
As a consequence of the massive vasodilation associated with septic shock, in the
early stages, cardiac output is high with low systemic vascular resistance. In septic
shock, pulmonary artery occlusion pressure is not elevated. In the early stages of
septic shock, systemic vascular resistance is low and cardiac output is high. In the
early stages of septic shock, cardiac output is high.

DIF: Cognitive Level: Knowledge

REF: p. 270 | Table 11-5

OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse is caring for a patient admitted with severe sepsis. Vital signs
assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120
beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a
right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which
intervention should the nurse carry out first?
a.

Acetaminophen suppository

b.

Blood cultures from two sites

c.

IV antibiotic administration

d.

Isotonic fluid challenge




ANS: D
Early goal-directed therapy in severe sepsis includes administration of IV fluids to
keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart
rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the
immediate priority. Broad-spectrum antibiotics are recommended within the first
hour; however, volume resuscitation is the priority in this scenario.

DIF: Cognitive Level: Analysis

REF: p. 270

OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

8. Which patient being cared for in the emergency department is most at risk for
developing hypovolemic shock?
a.

A patient admitted with abdominal pain and an
elevated white blood cell count

b.

A patient with a temperature of 102° F and a general
dermal rash

c.

A patient with a 2-day history of nausea, vomiting, and
diarrhea

d.

A patient with slight rectal bleeding from inflamed
hemorrhoids




ANS: C
Excessive external loss of fluid may occur through the gastrointestinal tract via
vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to
support significant fluid loss in the remaining patient scenarios.

DIF: Cognitive Level: Comprehension REF: p. 270
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

9. The nurse is caring for a patient admitted with cardiogenic shock.
Hemodynamic readings obtained with a pulmonary artery catheter include a
pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac
index (CI) of 1.0 L/min/m2. What is the priority pharmacological
intervention?
a.

Dobutamine (Dobutrex)

b.

Furosemide (Lasix)

c.

Phenylephrine (Neo-Synephrine)

d.

Sodium nitroprusside (Nipride)




ANS: A
Positive inotropic agents (e.g., dobutamine) are given to increase the contractile
force of the heart. As contractility increases, cardiac output and index increase and
improve tissue perfusion. Administration of furosemide will assist only in managing

fluid volume overload. Phenylephrine administration enhances vasoconstriction,
which may increase afterload and further reduce cardiac output. Sodium
nitroprusside is given to reduce afterload. There is no evidence to support a need
for afterload reduction in this scenario.

DIF: Cognitive Level: Analysis

REF: p. 265 | Table 11-4

OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

10. Ten minutes following administration of an antibiotic, the nurse assesses a
patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs
assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130
beats/min, and respirations 36 breaths/min. What is the priority
intervention?
a.

Diphenhydramine (Benadryl) 50 mg intravenously

b.

Epinephrine 3 to 5 mL of a 1:10,000 solution
intravenously

c.

Methylprednisolone (Solu-Medrol) 125 mg

intravenously

d.

Ranitidine (Zantac) 50 mg intravenously




ANS: B
The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension,
epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered
intravenously. Diphenhydramine (Benadryl) will help block histamine release, but
epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids,
such as methylprednisolone (Solu-Medrol), are used to reduce inflammation, but
epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine
(Zantac) will help block histamine release, but epinephrine is the drug of choice for
anaphylaxis with hypotension.

DIF: Cognitive Level: Analysis

REF: p. 271, 278 | Table 11-5

OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

11. A patient is admitted to the cardiac care unit with an acute anterior
myocardial infarction. The nurse assesses the patient to be diaphoretic and
tachypneic, with bilateral crackles throughout both lung fields. Following

insertion of a pulmonary artery catheter by the physician, which
hemodynamic values is the nurse most likely to assess?
a.

High pulmonary artery diastolic pressure and low
cardiac output

b.

Low pulmonary artery occlusive pressure and low
cardiac output




c.

Low systemic vascular resistance and high cardiac
output

d.

Normal cardiac output and low systemic vascular
resistance

ANS: A
In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial
pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure
increase and volume backs up into the pulmonary circulation and the right side of
the heart.

Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic
vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac
output is low and systemic vascular resistance is high in cardiogenic shock.

DIF: Cognitive Level: Analysis

REF: p. 275

OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. During the initial stages of shock, what are the physiological effects of
decreased cardiac output?
a.

Arterial vasodilation




b.

High urine output

c.

Increased parasympathetic stimulation

d.

Increased sympathetic stimulation

ANS: D
A reduction in blood pressure leads to an increase in catecholamine release,
resulting in an increase in heart rate and contractility to improve cardiac output.
Decreased cardiac output leads to arterial vasoconstriction in an effort to increase
blood pressure. Low urine output results, as decreased cardiac output reduces blood
flow to the kidneys. There is an increase in sympathetic stimulation in response to a
decrease in cardiac output.

DIF: Cognitive Level: Knowledge

REF: p. 258

OBJ: Correlate the four classifications of shock to their pathophysiology.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. While monitoring a patient for signs of shock, the nurse understands which
system assessment to be of priority?
a.

Central nervous system




b.

Gastrointestinal system

c.

Renal system

d.

Respiratory system

ANS: A
The central nervous system experiences decreased perfusion first. The patient will
have central nervous system changes early during the course of shock, such as
changes in the level of consciousness. Although the gastrointestinal, renal, and
respiratory systems also experience changes during shock, changes in the central
nervous system provide the earliest indication of decreased perfusion.

DIF: Cognitive Level: Knowledge

REF: p. 257

OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The nurse is caring for a patient in cardiogenic shock who is being treated
with an intraaortic balloon pump (IABP). The family inquires about the
primary reason for the device. What is the best statement by the nurse to
explain the IABP?
a.

“The action of the machine will improve blood supply
to the damaged heart.”




b.

“The machine will beat for the damaged heart with
every beat until it heals.”

c.

“The machine will help cleanse the blood of impurities
that might damage the heart.”

d.

“The machine will remain in place until the patient is
ready for a heart transplant.”

ANS: A
The IABP improves coronary artery perfusion, reduces afterload, and improves
perfusion to vital organs. An IABP acts through counterpulsation, augmenting the
pumping action of the heart, displacing blood to improve both forward and
backward blood flow. It does not “beat” for the damaged heart. An IABP does not
filter blood impurities. An IABP is designed as a temporary therapy for use when
pharmacological interventions alone are not effective. It is indicated for short-term
use, not as a bridge to transplant.

DIF: Cognitive Level: Comprehension REF: p. 275
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

15. The nurse is caring for a patient following insertion of an intraaortic balloon
pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which
hemodynamic parameter best indicates an appropriate response to therapy?




a.

Cardiac index (CI) of 2.5 L/min/m2

b.

Pulmonary artery diastolic pressure of 26 mm Hg

c.

Pulmonary artery occlusion pressure (PAOP) of 22
mm Hg

d.

Systemic vascular resistance (SVR) of 1600
dynes/sec/cm-5

ANS: A
Desired outcomes for a patient in cardiogenic shock with an IABP include decreased
SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment
elevation), increased stroke volume, and increased cardiac output and cardiac index.
A cardiac index of 2.5 L/min is within normal limits. All other values are high and
would not indicate an appropriate response to therapy.

DIF: Cognitive Level: Comprehension REF: p. 275
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

16. The nurse is caring for an 18-year-old athlete with a possible cervical spine
(C5) injury following a diving accident. The nurse assesses a blood pressure
of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min.
The patient’s skin is warm and flushed. What is the best interpretation of
these findings by the nurse?




a.

The patient is developing neurogenic shock.

b.

The patient is experiencing an allergic reaction.

c.

The patient most likely has an elevated temperature.

d.

The vital signs are normal for this patient.

ANS: A
The most profound feature of neurogenic shock is bradycardia with hypotension
from the decreased sympathetic activity. There is no evidence to support an allergic
reaction in this scenario. Hypothermia, not an elevated temperature, can develop
from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital
signs are not normal given the clinical situation.

DIF: Cognitive Level: Analysis

REF: pp. 276-277

OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

17. The nurse is caring for a patient in spinal shock. Vital signs include blood
pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24
breaths/min, oxygen saturation 95% on room air, and an oral temperature of
96.8° F. Which intervention is most important for the nurse to include in the
patient’s plan of care?




a.

Administration of atropine sulfate (Atropine)

b.

Application of 100% oxygen via facemask

c.

Application of slow rewarming measures

d.

Infusion of IV phenylephrine (Neo-Synephrine)

ANS: C
Hypothermia can develop in neurogenic shock from uncontrolled heat loss;
therefore, a patient should be rewarmed slowly to avoid further vasodilation. In
shock, a drop in systolic blood pressure to less than 90 mm Hg is considered
hypotensive. Atropine is used for symptomatic bradycardia. The patient’s oxygen
saturation is 95% on room air with an adequate respiratory rate. The application of
100% oxygen via facemask is not indicated. The patient’s heart rate is adequate to
support a normal blood pressure.

DIF: Cognitive Level: Application

REF: p. 277

OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

18. The nurse has just completed administration of a 1000-L bolus of 0.9%
normal saline. The nurse assesses the patient to be slightly confused, with a
mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110
beats/min, urine output of 10 mL for the past hour, and a central venous




pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these
results by the nurse?
a.

Patient response to therapy is appropriate.

b.

Additional interventions are indicated.

c.

More time is needed to assess response.

d.

Values are normal for the patient condition.

ANS: B
Assessed vital signs and hemodynamic values indicate decreased circulating

volume. The patient has not responded appropriately to therapy aimed at increasing
circulating volume. Additional intervention is needed because response to therapy
is not appropriate, values are abnormal, and timely intervention is critical for a
patient with low circulating blood volume.

DIF: Cognitive Level: Analysis

REF: p. 262

OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

19. The emergency department nurse admits a patient following a motor vehicle
collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140
beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen
saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results
include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L.




Based on this assessment, what is most important for the nurse to include in
the patient’s plan of care?
a.

Insertion of an 18-gauge peripheral intravenous line

b.

Application of cushioned heel protectors

c.

Implementation of fall precautions

d.

Implementation of universal precautions

ANS: A
Given the patient’s diagnosis, laboratory results, and supporting vital signs,
restoring circulating blood volume is a priority and can be accomplished following
insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration.
Universal precautions, fall precautions, and application of heel protectors are
appropriate interventions but are not the immediate priority.

DIF: Cognitive Level: Analysis

REF: p. 262

OBJ: Develop an individualized plan of care that includes nursing diagnosis,
expected outcomes, nursing interventions, and rationales.
TOP: Nursing
Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk

20. The nurse is starting to administer a unit of packed red blood cells (PRBCs) to
a patient admitted in hypovolemic shock secondary to hemorrhage. Vital
signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min,

respirations 42 breaths/min, and temperature 100.6° F. What is the best
action by the nurse?
a.

Administer blood transfusion over at least 4 hours.

b.

Notify the physician of the elevated temperature.

c.

Titrate rate of blood administration to patient
response.

d.

Notify the physician of the patient’s heart rate.

ANS: C
Given the acute nature of the patient’s blood loss, the nurse should titrate the rate of
the blood transfusion to an improvement in the patient’s blood pressure.
Administering the transfusion over 4 hours can lead to a prolonged state of
hypoperfusion and end-organ damage. The heart rate will normalize as circulating
blood volume is restored. A mildly elevated temperature does not take priority over
restoring circulating blood volume.

DIF: Cognitive Level: Analysis

REF: p. 264

OBJ: Develop an individualized plan of care that includes nursing diagnosis,
expected outcomes, nursing interventions, and rationales.
TOP: Nursing
Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk




21. The nurse is caring for a patient in septic shock. The nurse assesses the
patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min,
respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45%
supplemental oxygen via Venturi mask, and a temperature of 102° F. The
physician orders stat administration of an antibiotic. Which additional
physician order should the nurse complete first?
a.

Blood cultures

b.

Chest x-ray

c.

Foley insertion

d.

Serum electrolytes

ANS: A
Timely identification of the causative organism through blood cultures and the
initiation of appropriate antibiotics following obtaining blood cultures improve the
survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and
measurement of serum electrolytes may be included in the plan of care but are not
the priority in this scenario.

DIF: Cognitive Level: Analysis

REF: p. 282

OBJ: Develop an individualized plan of care that includes nursing diagnosis,
expected outcomes, nursing interventions, and rationales.
TOP: Nursing
Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk




22. The nurse is caring for a patient admitted to the critical care unit 48 hours
ago with a diagnosis of severe sepsis. As part of this patient’s care plan, what
intervention is most important for the nurse to discuss with the
multidisciplinary care team?
a.

Frequent turning

b.

Monitoring intake and output

c.

Enteral feedings

d.

Pain management

ANS: C
Initiation of enteral feedings within 24 to 48 hours of admission is critical in
reducing the risk of infection by assisting in maintaining the integrity of the
intestinal mucosa. Monitoring intake and output, frequent turning, and pain
management are important aspects of care but are not a critical priority during the
first 24 to 48 hours following admission.

DIF: Cognitive Level: Analysis

REF: p. 268

OBJ: Develop an individualized plan of care that includes nursing diagnosis,
expected outcomes, nursing interventions, and rationales.
TOP: Nursing
Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk




23. The nurse is administering both crystalloid and colloid intravenous fluids as
part of fluid resuscitation in a patient admitted in severe sepsis. What
findings assessed by the nurse indicate an appropriate response to therapy?
a.

Normal body temperature

b.

Balanced intake and output

c.

Adequate pain management

d.

Urine output of 0.5 mL/kg/hr

ANS: D
Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the
kidneys following administration of fluid to enhance circulating blood volume.
Normal body temperature and adequate pain management are not assessment
findings indicating an adequate response to fluid therapy. During fluid resuscitation
in severe sepsis, intake and output will not be balanced as circulating fluid volume

deficit is restored.

DIF: Cognitive Level: Comprehension REF: p. 268
OBJ: Develop an individualized plan of care that includes nursing diagnosis,
expected outcomes, nursing interventions, and rationales.
TOP: Nursing
Process Step: Assessment
MSC: NCLEX: Physiological Adaptation




24. The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial
assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125
beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP)
of 3 mm Hg, and urine output of 5 mL during the past hour. Following
physician rounds, the nurse reviews the orders and questions which order?
a.

Administer acetaminophen (Tylenol) 650-mg
suppository prn every 6 hours for pain.

b.

Titrate dopamine (Intropin) intravenously for blood
pressure < 90 mm Hg systolic.

c.

Complete neurological assessment every 4 hours for

the next 24 hours.

d.

Administer furosemide (Lasix) 20 mg IV every 4 hours
for a CVP > 20 mm Hg.

ANS: B
Vasoconstrictive agents should not be administered for hypotension in the presence
of circulation fluid volume deficit. The nurse should question the use of the
dopamine (Intropin) infusion. All other listed orders are appropriate and have
potential for use in the treatment of a hypovolemic shock.

DIF: Cognitive Level: Analysis

REF: Table 11-4

OBJ: Develop an individualized plan of care that includes nursing diagnosis,
expected outcomes, nursing interventions, and rationales.
TOP: Nursing
Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk