Chapter 67 Nursing Management Shock Systemic Inflammatory R

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Chapter 67: Nursing Management: Shock, Systemic Inflammatory Response
Syndrome, and Multiple Organ Dysfunction Syndrome
Test Bank
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.

Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other
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In preparation for the patient’s arrival, the nurse will obtain
a. hypothermia blanket.
b. lactated Ringer’s solution.
c. two 14-gauge IV catheters.
d. dopamine (Intropin) infusion.

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 has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
9. Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic

shock has been effective?
a. Hemoglobin is within normal limits.
b. Urine output is 60 mL over the last hour.
c. Central venous pressure (CVP) is normal.
d. Mean arterial pressure (MAP) is 72 mm Hg.

Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.
DIF: Cognitive Level: Apply (application)