Understanding The Essentials Of Critical Care Nursing By Perrin -Test Bank Care of the Patient Experiencing Shock or Heart Failure

Understanding The Essentials Of Critical Care Nursing By Perrin -Test Bank Care of the Patient Experiencing Shock or Heart Failure Q1) Which of the following should the nurse identify as symptoms of hypovolemic shock? (Select all that apply.) 1. A temperature of 97.6°F (36.4°C) 2. A decrease in blood pressure of 20 mm Hg when the patient sits up 3. Capillary refill time greater than 3 seconds 4. Restlessness 5. Sinus bradycardia of 55 beats per minute Answer: 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 137 4. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 5. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 6-1: Recognize the manifestations of hypovolemia Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 138 2) Which of the following lab findings should cause the nurse to suspect that a patient was developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic alkalosis validated by arterial blood gases 3. Serum lactate of 5 mmol/L 4. SvO2 greater than 80% Answer: 2 Explanation: 1. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased concentration of sodium occurs when the circulating volume is decreased, concentrating the elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased. The normal values for SvO2 are between 60% and 80%. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased concentration of sodium occurs when the circulating volume is decreased, concentrating the elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased. The normal values for SvO2 are between 60% and 80%. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased concentration of sodium occurs when the circulating volume is decreased, concentrating the elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased. The normal values for SvO2 are between 60% and 80%. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 139 4. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased concentration of sodium occurs when the circulating volume is decreased, concentrating the elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased. The normal values for SvO2 are between 60% and 80%. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 6-1: Recognize the manifestations of hypovolemia Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 140 3) The nurse should recognize that which of the following patients would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output. 2. Severe constipation, causing watery diarrhea. 3. Ascites. 4. Syndrome of inappropriate ADH (SIADH). Answer: 3 Explanation: 1. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 141 4. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 6-1: Recognize the manifestations of hypovolemia Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 142 4) Which of the following findings would indicate that a patientʹs peripheral vascular resistance was increased? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time Answer: 2 Explanation: 1. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 143 Learning Outcome: 6-2: Describe hemodynamic findings indicative of hypovolemia 5) Which of the following solutions would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringerʹs lactate (RL) over 15 minutes 3. Two liters of D5W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour Answer: 2 Explanation: 1. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long enough to expand the circulating volume nor would it replace the lost cells needed to carry oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long enough to expand the circulating volume nor would it replace the lost cells needed to carry oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long enough to expand the circulating volume nor would it replace the lost cells needed to carry oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long enough to expand the circulating volume nor would it replace the lost cells needed to carry oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 6-2: Describe hemodynamic findings indicative of hypovolemia Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 144 6) Which life-threatening complications would the nurse anticipate might develop in the patient who is being treated for hypovolemic shock? (Select all that apply.) 1. Renal insufficiency (RI)/renal failure (RF) 2. Cerebral ischemia 3. Irreversible shock 4. Gastric stress ulcer Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct responses for complications that can occur from tissue hypoxia and decreased capillary perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although physiological stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct responses for complications that can occur from tissue hypoxia and decreased capillary perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although physiological stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct