Exam 2 NUR 2115 Practice Questions
and Correct Answers
How to calculate cardiac output ✅CO = SV x HR
Mean Arterial Pressure (MAP) ✅MAP= SBP + 2(DBP) / 3
Normal= 70-105mmhg
Needs to be >65mmhg to perfuse ONLY the vital organs. THIS IS NOT NORMAL
Use A line to measure
Pulmonary Artery Catheter Pressures ✅PA pressures- (distal port)
PAS= 15-30mmhg
PAD 8-15mmhg
SIRS ✅systemic inflammatory response syndrome.
Does not have to be associated with an infection.
SIRS criteria ✅need 2 or more s/s
-temp >100.4, temp <96.8
-HR >90bpm
-RR >20 and /or PCO2 <32 (rapid breathing)
-WBC >12,000 or <4,000
WOTF is not criteria s/s for dx SIRS
1. RR > 20
2. HR <60
3. Temp >100.4
4. Paco2 <32 ✅2. HR <60 ANSWER
DIC ✅disseminated intravascular coagulation
DEATH IS COMING
NO PERFUSION
They will have an increased D Dimer
DIC clinical presentation ✅Acute bleeding from multiple sites. Bleeding from
everywhere. Organ dysfunction, Thrombosis.
DIC nursing management ✅1. Occult blood testing of all fluids
2. Avoid puncturing the pt.
3. Apply pressure 10-15 MIN for arterial puncture. 5MIN for venous puncture.
4. Paper tape
5. No BP cuff. NEED AN A LINE
6. No rectal temp
, 7. Gentle personal care
8. Dec. Pressure points
9. Monitor pupils for changes- Could be cerebral bleed.
WOTF lab value is indicative of DIC
1. Dec PTT
2. Inc Platelet
3. Dec INR
4. Inc FDP (fibrin degradation product) ✅4. Inc FDP (fibrin degradation product)
ANSWER
Hypovolemic shock ✅TANK PROBLEM
Inadequate fluid volume in the space
Cardiogenic shock ✅PUMP PROBLEM
Coronary- problem with heart itself, cant move blood.
Non-Coronary- physical obstruction into or out of heart
Circulatory (distributive) shock ✅PIPE PROBLEM ---> EXTREME VASODILATION
Septic shock- inflammatory response due to invasion of organism
Anaphylactic- antigen-antibody response
Shock initially ✅Dont see anything at first. Will just have a lactic acid buildup.
Compensatory stage ✅blood shunted to most vital organs.
Increased heart rate to maintain adequate BP & CO
RR increases to compensate for met. Acidosis
Compensatory stage s/s ✅increased HR, adequate BP (>65), narrowing PP, increased
RR, cool pale skin, hypoactive bowel sounds, decreased urine output.
Compensatory stage effects on kidney ✅releases renin. Releases aldosterone.
Compensatory stage effects on pituitary ✅secretes ADH. Clinical s/s- dec urine output.
Adequate BP (>65)
Compensatory stage SEPSIS s/s ✅warm flushed skin, increased temp, bounding
pulse
Progressive stage ✅compensatory mechanisms fail causing anasarca (major swelling)
Progressive stage effects on pulmonary system ✅pulmonary hypertension, ARDS
Progressive stage effects on cardiovascular system ✅myocardial dysfunction
and Correct Answers
How to calculate cardiac output ✅CO = SV x HR
Mean Arterial Pressure (MAP) ✅MAP= SBP + 2(DBP) / 3
Normal= 70-105mmhg
Needs to be >65mmhg to perfuse ONLY the vital organs. THIS IS NOT NORMAL
Use A line to measure
Pulmonary Artery Catheter Pressures ✅PA pressures- (distal port)
PAS= 15-30mmhg
PAD 8-15mmhg
SIRS ✅systemic inflammatory response syndrome.
Does not have to be associated with an infection.
SIRS criteria ✅need 2 or more s/s
-temp >100.4, temp <96.8
-HR >90bpm
-RR >20 and /or PCO2 <32 (rapid breathing)
-WBC >12,000 or <4,000
WOTF is not criteria s/s for dx SIRS
1. RR > 20
2. HR <60
3. Temp >100.4
4. Paco2 <32 ✅2. HR <60 ANSWER
DIC ✅disseminated intravascular coagulation
DEATH IS COMING
NO PERFUSION
They will have an increased D Dimer
DIC clinical presentation ✅Acute bleeding from multiple sites. Bleeding from
everywhere. Organ dysfunction, Thrombosis.
DIC nursing management ✅1. Occult blood testing of all fluids
2. Avoid puncturing the pt.
3. Apply pressure 10-15 MIN for arterial puncture. 5MIN for venous puncture.
4. Paper tape
5. No BP cuff. NEED AN A LINE
6. No rectal temp
, 7. Gentle personal care
8. Dec. Pressure points
9. Monitor pupils for changes- Could be cerebral bleed.
WOTF lab value is indicative of DIC
1. Dec PTT
2. Inc Platelet
3. Dec INR
4. Inc FDP (fibrin degradation product) ✅4. Inc FDP (fibrin degradation product)
ANSWER
Hypovolemic shock ✅TANK PROBLEM
Inadequate fluid volume in the space
Cardiogenic shock ✅PUMP PROBLEM
Coronary- problem with heart itself, cant move blood.
Non-Coronary- physical obstruction into or out of heart
Circulatory (distributive) shock ✅PIPE PROBLEM ---> EXTREME VASODILATION
Septic shock- inflammatory response due to invasion of organism
Anaphylactic- antigen-antibody response
Shock initially ✅Dont see anything at first. Will just have a lactic acid buildup.
Compensatory stage ✅blood shunted to most vital organs.
Increased heart rate to maintain adequate BP & CO
RR increases to compensate for met. Acidosis
Compensatory stage s/s ✅increased HR, adequate BP (>65), narrowing PP, increased
RR, cool pale skin, hypoactive bowel sounds, decreased urine output.
Compensatory stage effects on kidney ✅releases renin. Releases aldosterone.
Compensatory stage effects on pituitary ✅secretes ADH. Clinical s/s- dec urine output.
Adequate BP (>65)
Compensatory stage SEPSIS s/s ✅warm flushed skin, increased temp, bounding
pulse
Progressive stage ✅compensatory mechanisms fail causing anasarca (major swelling)
Progressive stage effects on pulmonary system ✅pulmonary hypertension, ARDS
Progressive stage effects on cardiovascular system ✅myocardial dysfunction
