Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Test Bank

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. Potassium3.8 mEq/L d. Sodium140 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