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Chapter 69: Nursing Management: Shock, Systemic Inflammatory ResponseSyndrome, and Multiple-Organ Dysfunction Syndrome
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client with septic shock who has had a urine output of 20
mL/hour for the past 3 hours. The pulse rate is 120 and the central venous pressure and
pulmonary artery wedge pressure are low. Which of the following orders by the health
care provider should the nurse question?
a. Administer furosemide 40 mg IV.
b. Increase normal saline infusion to 150 mL/hour.
c. Administer hydrocortisone 100 mg IV.
d. Administer dopamine 5 mcg/kg/minute IV.
ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the client with
septic shock. The other orders are appropriate.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a client with shock of unknown etiology whose hemodynamic
monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure.
Which of the following prescribed interventions should the nurse question?
a. Infuse normal saline at 250 mL/hour.
b. Keep head of bed elevated to 30 degrees.
c. Give nitroprusside unless systolic BP <90 mm Hg.
d. Administer dobutamine to keep systolic BP >90 mm Hg.
ANS: A
The client’s elevated pulmonary artery wedge pressure indicates volume excess. A normal
saline infusion at 250 mL/hour will exacerbate this. The other actions are appropriate for
the client.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a client in the emergency department with massive trauma and
possible spinal cord injury. Which of the following findings by the nurse will help confirm
a diagnosis of neurogenic shock?
a. Cool, clammy skin
b. Inspiratory crackles
c. Apical heart rate 48 beats/minute
d. Temperature 38.4°C (101.1°F)
ANS: C
Neurogenic shock is characterized by hypotension and bradycardia. The other findings
would be more consistent with other types of shock.
, DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a client with noncardiogenic shock who is cool, clammy and whose
hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which of
the following actions should the nurse anticipate implementing?
a. Increase the rate for the prescribed dopamine infusion.
b. Decrease the rate for the prescribed nitroglycerin infusion.
c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion.
d. Increase the rate for the prescribed sodium nitroprusside infusion.
ANS: D
Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will
improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly
increase SVR. Increasing the dopamine will tend to increase SVR.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
5. After receiving 1 000 mL of normal saline, the central venous pressure for a client who
has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. Which of the
following prescribed medications should the nurse administer?
a. Nitroglycerin
b. Drotrecogin-a
c. Norepinephrine
d. Sodium nitroprusside
ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase
the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would
decrease the preload and further drop cardiac output and BP. Drotrecogin-a may decrease
inappropriate inflammation and help prevent systemic inflammatory response syndrome,
but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and
would further decrease SVR.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
6. Which of the following assessments should the nurse make to evaluate the effectiveness of
omeprazole administration to a client with systemic inflammatory response syndrome
(SIRS)?
a. Auscultate bowel sounds.
b. Ask the client about nausea.
c. Monitor stools for occult blood.
d. Check for abdominal distention.
ANS: C
Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill
clients. The other assessments also will be done, but these will not help in determining the
effectiveness of the omeprazole administration.
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