In a patient with septic shock, which complication will the nurse remain alert for?
Neurogenic shock.
Febrile seizures.
Esophageal varices.
Acute Respiratory Distress Syndrome.
The Correct Answer is D
Choice A reason: Neurogenic shock is a type of distributive shock that occurs due to a sudden loss of sympathetic nervous system signals to the smooth muscle in vessel walls. It is not a direct complication of septic shock, which is primarily caused by severe infection and systemic inflammation. While both are forms of shock, the mechanisms and causes are different.
Choice B reason: Febrile seizures are typically seen in children with high fevers and are not a common complication of septic shock in adults. Septic shock involves severe infection and systemic inflammatory response, leading to complications such as organ failure rather than febrile seizures.
Choice C reason: Esophageal varices are enlarged veins in the esophagus that can bleed, often seen in patients with liver disease and portal hypertension. They are not a complication of septic shock. While severe infection and systemic inflammation can lead to various complications, esophageal varices are specifically related to liver pathology.
Choice D reason: Acute Respiratory Distress Syndrome (ARDS) is a severe complication that the nurse should remain alert for in patients with septic shock. ARDS is characterized by rapid onset of widespread inflammation in the lungs, leading to respiratory failure. It is a common and serious complication of septic shock due to the systemic inflammatory response affecting the lung tissue. Early recognition and management are crucial for improving patient outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: An increase in serum hematocrit indicates that epoetin has been effective. Epoetin, also known as erythropoietin, is a medication used to stimulate the production of red blood cells. In patients with chronic kidney disease, the kidneys may not produce enough natural erythropoietin, leading to anemia. By administering epoetin, the goal is to increase red blood cell production, which is reflected in higher hematocrit levels (the proportion of red blood cells in the blood).
Choice B reason: An increase in serum calcium is not related to the effectiveness of epoetin. Serum calcium levels are regulated by different mechanisms, including parathyroid hormone and vitamin D, and are not directly influenced by epoetin administration.
Choice C reason: A decrease in serum creatinine levels would indicate improved kidney function, but this is not the expected outcome of epoetin therapy. Epoetin specifically targets red blood cell production and does not have a direct impact on kidney function or creatinine levels.
Choice D reason: A decrease in blood pressure is also not an expected indicator of epoetin effectiveness. While managing blood pressure is important in chronic kidney disease, epoetin's primary role is to address anemia by stimulating red blood cell production. Blood pressure regulation involves other medications and interventions.
Correct Answer is C
Explanation
Choice A reason: Medicating the patient for pain is not the most appropriate immediate action in this situation. While pain management is important, the primary concern should be addressing the significant changes in heart rate and blood pressure, which may indicate a more serious underlying issue.
Choice B reason: Allowing the patient to rest quietly is not the appropriate response to the noted changes in vital signs. The increase in heart rate and drop in blood pressure are signs that require immediate investigation and intervention, rather than passive observation.
Choice C reason: Assessing the patient for bleeding is the most appropriate action. The increase in heart rate and decrease in blood pressure following an angioplasty procedure are concerning for potential bleeding or hemorrhage, especially if the patient has an intra-arterial line. Quick assessment and intervention are crucial to address any bleeding and stabilize the patient's condition.
Choice D reason: Documenting the findings in the chart is necessary, but it should not be the immediate priority. The nurse must first assess and address the potential cause of the changes in vital signs, such as bleeding, before documenting the events.
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