Shock Recognition and Stages
A patient with early shock presents with:
HR 110
BP 118/72
cool pale skin
anxiety
Which stage of shock is most likely occurring?
Compensatory (preshock) stage
Rationale
The body maintains blood pressure through tachycardia and vasoconstriction, so BP may still appear normal.
A patient arrives to the ED with suspected septic shock.
Vital signs:
BP 86/50
HR 124
Temp 39.2°C
Lactate elevated
What is the priority nursing intervention?
Administer a rapid IV fluid bolus (0.9% NS or LR).
Rationale
Initial management of septic shock focuses on fluid resuscitation to restore perfusion before vasopressors.
A patient with septic shock remains hypotensive despite receiving adequate IV fluids.
Which medication is considered the first-line vasopressor?
Norepinephrine
Rationale
Norepinephrine causes potent vasoconstriction, increasing systemic vascular resistance and improving blood pressure in septic shock.
A patient with severe burns develops dark, reddish-brown urine after sustaining an electrical burn.
What complication should the nurse suspect?
Myoglobinuria from muscle breakdown
Rationale
Electrical burns can cause extensive muscle damage, releasing myoglobin into the bloodstream, which can damage the kidneys.
A patient with extensive burns is being assessed in the emergency department.
Which intervention should the nurse prioritize first?
A. Start IV fluids
B. Administer pain medication
C. Assess airway and breathing
D. Apply burn dressings
C. Assess airway and breathing
Rationale
Burn management follows ABCs (airway, breathing, circulation). Airway compromise from inhalation injury can occur rapidly.
A patient with progressing shock develops:
hypotension
decreased urine output
confusion
metabolic acidosis
Which stage of shock is most likely occurring?
Progressive (uncompensated) shock
Rationale
Compensatory mechanisms begin failing, leading to organ hypoperfusion and metabolic acidosis.
A patient in hypovolemic shock has:
BP 78/40
HR 132
cold clammy skin
urine output 10 mL/hr
What is the priority nursing intervention?
Initiate rapid IV fluid replacement.
Rationale
Hypovolemic shock results from loss of circulating volume, so the priority is restoring blood volume.
A patient experiencing anaphylactic shock develops:
airway swelling
wheezing
hypotension
Which medication should the nurse administer immediately?
Epinephrine
Rationale
Epinephrine causes bronchodilation, vasoconstriction, and increased cardiac output, making it the first-line treatment for anaphylaxis.
A patient with major burns suddenly develops:
abdominal distention
decreased bowel sounds
nausea and vomiting
Which complication should the nurse suspect?
Paralytic ileus
Rationale
Severe burns and stress can impair GI motility, leading to paralytic ileus.
A patient with severe burns is at high risk for hypothermia.
Which nursing intervention helps prevent heat loss?
Keep the patient covered with clean dry sheets or blankets and maintain a warm room environment.
Rationale
Burn patients lose heat easily due to loss of the protective skin barrier.
A patient in septic shock initially presents with:
warm flushed skin
bounding pulses
tachycardia
Which type of shock is most consistent with these findings?
Distributive shock (septic shock)
Rationale
Early septic shock causes vasodilation, producing warm skin and bounding pulses.
A patient with septic shock receives adequate IV fluids but remains hypotensive with:
MAP 58 mmHg
Which medication should the nurse anticipate next?
Norepinephrine infusion
Rationale
Norepinephrine is the first-line vasopressor for septic shock when fluids alone cannot maintain MAP ≥65 mmHg.
A patient in cardiogenic shock after a myocardial infarction has decreased cardiac output and poor tissue perfusion.
Which medication should the nurse anticipate administering to increase cardiac contractility?
Dobutamine
Rationale
Dobutamine is an inotrope that increases cardiac contractility and cardiac output.
A patient with severe burns is at risk for Curling’s ulcer.
What is the primary cause of this complication?
Decreased blood flow to the gastrointestinal mucosa due to severe stress and hypovolemia
Rationale
Curling’s ulcers are stress-related gastric or duodenal ulcers that occur after major burns.
A patient with extensive burns is receiving fluid resuscitation.
Which finding best indicates that fluid therapy is effective?
Urine output ≥0.5 mL/kg/hr
Rationale
Adequate urine output indicates sufficient kidney perfusion and circulating volume.
A trauma patient presents with:
hypotension
tachycardia
cool clammy skin
narrow pulse pressure
Which type of shock is most likely?
Hypovolemic shock
Rationale
Loss of circulating blood volume results in tachycardia and vasoconstriction.
A patient with burn injuries develops increasing tightness, pain, and decreased pulses in the burned extremity.
What complication should the nurse suspect and report immediately?
Compartment syndrome
Rationale
Burn edema can increase tissue pressure and compromise circulation, requiring urgent intervention (often escharotomy).
A patient receiving dopamine infusion for shock develops tachycardia and dysrhythmias.
What is the priority nursing action?
Notify the provider and reassess the infusion rate.
Rationale
Dopamine can cause significant tachyarrhythmias, which may worsen myocardial oxygen demand.
A burn patient initially develops hyperkalemia but later develops hypokalemia during treatment.
Why does this occur?
Initial cell destruction releases potassium, but later fluid resuscitation and cellular shifts move potassium back into cells.
Rationale
Burn injuries cause cell lysis → hyperkalemia, followed by dilution and intracellular shifts → hypokalemia.
During burn wound care, which nursing action is most important to prevent infection?
Strict sterile technique during wound care.
Rationale
Burn wounds are extremely vulnerable to infection because the skin barrier is destroyed.
A patient with myocardial infarction develops:
hypotension
pulmonary edema
crackles
decreased cardiac output
Which type of shock should the nurse suspect?
Cardiogenic shock
Rationale
The heart cannot pump effectively, leading to decreased cardiac output and pulmonary congestion.
A burn patient develops:
hoarse voice
soot around mouth
singed nasal hairs
difficulty breathing
What is the priority nursing intervention?
Prepare for early endotracheal intubation.
Rationale
These findings indicate inhalation injury, and airway edema can rapidly cause complete airway obstruction.
A patient in septic shock is receiving norepinephrine infusion.
Which finding best indicates the medication is working effectively?
A. MAP increases to ≥65 mmHg
B. Heart rate decreases to 60 bpm
C. Urine output stops
D. Skin becomes pale
A. MAP increases to ≥65 mmHg
Rationale
The goal of vasopressor therapy in shock is to maintain adequate organ perfusion, typically defined as MAP ≥65 mmHg.
A patient with major burns develops:
fever
increasing heart rate
confusion
hypotension
Which life-threatening complication should the nurse suspect?
Sepsis
Rationale
Burn patients are at extremely high risk for infection and sepsis because the protective skin barrier is lost.
A patient with deep full-thickness burns reports little to no pain at the burn site.
How should the nurse interpret this finding?
Full-thickness burns destroy nerve endings, which reduces sensation.
Rationale
Although surrounding areas may be painful, the deepest burn tissue may have little sensation due to nerve damage.