INTRODUCTION TO CRITICAL CARE NURSING 7TH EDITION SOLE TEST BANK
Chapter 12: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Sole: Introduction to Critical Care Nursing, 7th Edition MULTIPLE CHOICE 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 inappropriate without further attempts using different modalities. DIF: Cognitive Level: Apply/Application REF: p. 260 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a NURSINGTB.COM
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. Potassium 3.8 mEq/L d. Sodium 140 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: Remember/Knowledge REF: p. 263 Laboratory Alert box OBJ: Relate assessment findings to the classification and stage of shock. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. The nurse has been administering 0.9% normal saline intravenous fluids in a patient with
severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output
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