Shock
A client develops fever, hypotension, agitation, and warm, flushed skin following a severe infection. Identify the type of shock associated with these manifestations.
Septic shock. An infection-related vasodilation decreases systemic vascular resistance, producing warm, flushed skin during early septic shock.
A client receiving central venous pressure monitoring has a CVP of 1 mmHg and signs of dehydration. Identify the prescribed intervention most appropriate to restore circulating volume.
Answer: IV fluid administration. Rationale: A very low CVP suggests reduced venous return and possible hypovolemia.
A patient arrives in the emergency department with partial-thickness burns involving 30% of the total body surface area. During the first 24 hours, which IV solution should the nurse anticipate administering to prevent circulatory collapse?
Answer: Lactated Ringer's. Rationale: Major burns cause significant fluid shifts, increasing the risk of hypovolemic shock. Lactated Ringer's is commonly used for initial burn resuscitation.
A client is admitted after severe hemorrhage. The nurse identifies hypotension, decreased urine output, and elevated BUN and creatinine. Diagnostic findings suggest reduced kidney perfusion without direct injury to the kidney tissue. What type of acute kidney injury is the client experiencing?
Answer: Prerenal AKI. Rationale: Severe blood loss and hypotension reduce renal blood flow, decreasing glomerular perfusion and filtration.
A client arrives with frostbite affecting the fingers. The nurse notices rings and tight clothing around the injured extremity before beginning rewarming. What should the nurse do to prevent worsening tissue constriction?
Answer: Remove the rings and restrictive clothing. Rationale: Swelling develops as frozen tissue thaws. Removing restrictive items helps prevent additional circulatory compromise.
A patient in the early stage of shock develops restlessness, tachycardia, and increased respiratory rate despite maintaining a normal blood pressure. What stage of shock is the patient experiencing?
Answer: Compensatory stage. Rationale: The sympathetic nervous system attempts to preserve perfusion by increasing heart rate and respiratory rate.
A patient receiving continuous arterial pressure monitoring has an order for IV norepinephrine. A newly licensed nurse prepares to administer the medication through the arterial catheter because it provides direct vascular access. What action should the supervising nurse take?
Answer: Stop the medication administration. Rationale: An arterial line is used for invasive blood pressure monitoring and arterial sampling, not routine medication administration. Medications should be administered through appropriate venous access.
A nurse is caring for a client with 30% of the total body surface area with deep partial-thickness and full-thickness burns to the upper anterior chest and the entire left arm. Which is the priority nursing assessment?
Check for Presence of pulses in the arm
A client with acute kidney injury is receiving multiple medications. The nurse reviews the prescribed medications and identifies vancomycin, an aminoglycoside, and a nonsteroidal anti-inflammatory drug. Which medication-related complication should the nurse be most concerned about?
Answer: Nephrotoxicity. Rationale: All three medications are identified in your notes as potentially nephrotoxic and may worsen kidney injury.
A client arrives at the emergency department after being stung by a bee. The nurse observes facial swelling, wheezing, stridor, and a blood pressure of 78/42 mmHg. The client becomes increasingly anxious and reports difficulty breathing. Which medication should the nurse anticipate administering first to prevent cardiovascular collapse?
Answer: Epinephrine.
A patient with a spinal cord injury at T5 develops a blood pressure of 78/42 mmHg, heart rate of 44/min, and warm, dry skin. Identify the shock state most consistent with these findings.
Neurogenic shock. Rationale: Loss of sympathetic tone causes vasodilation, hypotension, and bradycardia.
A patient with heart failure has a cardiac output of 2.4 L/min, MAP of 55 mmHg, and decreasing urine output. Which prescribed medication should the nurse anticipate improving myocardial contractility?
Answer: Dobutamine. Rationale: Dobutamine increases the force of cardiac contractions, improving cardiac output and organ perfusion.
A client rescued from an enclosed-space fire has facial burns, hoarseness, carbonaceous sputum, and increasing difficulty swallowing. Which intervention should the nurse anticipate first to prevent a life-threatening complication?
Answer: Prepare for early endotracheal intubation. Rationale: Progressive airway edema can obstruct ventilation. Securing the airway takes priority over wound care and fluid replacement.
A client develops decreased urine output and elevated creatinine after an obstruction prevents urine drainage. Diagnostic testing identifies a bladder tumor. The nurse recognizes that kidney function may recover if the obstruction is relieved promptly. What type of AKI is occurring?
Answer: Postrenal AKI. Rationale: Postrenal AKI results from an obstruction to urine flow. Your notes state that complete recovery is likely if the obstruction is relieved within 48 hours.
A client with a lower-extremity fracture in traction develops severe pain, paresthesia, pallor, and decreasing distal pulses. Which surgical intervention should the nurse anticipate?
Answer: Fasciotomy. Rationale: These manifestations suggest compartment syndrome. Surgical decompression may be necessary to restore tissue perfusion.
A patient develops sudden dyspnea, chest pain, hypotension, and jugular venous distention following a massive pulmonary embolism. Which classification of shock should the nurse suspect?
Answer: Obstructive shock. Rationale: A pulmonary embolism physically obstructs blood flow, reducing cardiac output.
An arterial-line waveform suddenly becomes flattened, although the patient remains alert and has palpable pulses. Identify the equipment problem the nurse should investigate first.
Answer: Tubing obstruction or air bubbles. Rationale: Kinks, air bubbles, clots, and disconnections may produce a dampened arterial waveform.
A client with burns covering 40% of the body is receiving IV Lactated Ringer’s for fluid resuscitation. Four hours after admission, the nurse notes a urine output of 15 mL/hr, heart rate of 128/min, and MAP 58 mmHg. Which complication should the nurse suspect, and what intervention should be prioritized?
Answer: Hypovolemic shock — reassess and increase IV fluid resuscitation as prescribed.
A client with kidney failure requires dialysis. Instead of using an artificial membrane to filter the blood, the prescribed treatment involves introducing dialysis solution into the abdominal cavity to remove waste products and excess fluid. What type of dialysis is being used?
Answer: Peritoneal dialysis.
A client is admitted to the emergency department after being hit by a car. A fracture of the cervical spine is suspected. What is the priority nursing action?
Immobilize the cervical spine
While preparing an arterial pressure monitoring system, the nurse closes the stopcock toward the patient and opens it to atmospheric air. What procedure should the nurse perform next to establish the pressure reference?
Answer: Zero the transducer. Rationale: Zeroing establishes atmospheric pressure as the reference point for accurate invasive pressure measurements.
A 19-kg client is admitted to the emergency department with burns covering 38% of the total body surface area. The provider orders fluid resuscitation using the Parkland formula. How many milliliters of Lactated Ringer’s should the nurse administer during the first 8 hours after the injury?
Answer: 1,444 mL.
Rationale: 4 mL × 19 kg × 38 = 2,888 mL total over 24 hours. First 8 hours: 1,444 mL. Following 16 hours: 1,444 mL. Remember: The first 8 hours begin at the time of the burn injury, not hospital admission.
A critically ill client with acute kidney injury requires dialysis but remains hemodynamically unstable. The nurse anticipates a treatment that operates continuously over 24 hours, allowing fluid and waste products to be removed gradually rather than during a shorter dialysis session. What type of renal replacement therapy is most appropriate?
Answer: Continuous renal replacement therapy (CRRT). Rationale: CRRT provides continuous, gradual removal of waste products and fluid and is used for hemodynamically unstable, critically ill clients.
A client experiences severe hyperthermia, followed by skeletal muscle breakdown and decreasing urine output. The nurse recognizes that this complication can cause acute kidney injury. What complication is developing?
Answer: Rhabdomyolysis. Rationale: Muscle breakdown releases myoglobin, increasing the risk of kidney injury.