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 B
Explanation
Choice A reason: A urine output of 40 mL/hr is within the acceptable range, as normal urine output is typically around 30-50 mL/hr. While it should be monitored, it does not indicate an immediate life-threatening issue requiring urgent assessment.
Choice B reason: A blood pressure change from 128/74 to 110/88 mmHg may indicate potential hemodynamic instability. Although the systolic blood pressure has decreased, the diastolic pressure has increased, which can be concerning. This patient may be at risk for developing more significant blood pressure changes or other complications, making this situation the highest priority for assessment.
Choice C reason: An oxygen saturation level of 94% is generally considered acceptable. While it is on the lower end of the normal range, it does not indicate an immediate life-threatening condition. Continuous monitoring is important, but it is not the most urgent situation compared to the blood pressure change.
Choice D reason: A pulse change from 100 to 88 beats/min represents a decrease in heart rate but remains within the normal range for adult heart rate (60-100 beats/min). While this change should be noted and monitored, it is not as urgent as the blood pressure change that may indicate hemodynamic instability.
Correct Answer is A
Explanation
Choice A reason: Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments for a client in acute respiratory failure who is receiving mechanical ventilation. ABG provides essential information about the patient's oxygenation status, carbon dioxide levels, and acid-base balance. It allows healthcare providers to assess how well the lungs are oxygenating the blood and removing carbon dioxide. By analyzing the ABG results, the effectiveness of the mechanical ventilation and any necessary adjustments can be made to improve the client's respiratory status.
Choice B reason: Blood pressure monitoring is important for evaluating the overall cardiovascular status of a patient but is not the most specific assessment for determining the effectiveness of treatments in acute respiratory failure. While blood pressure can provide indirect information about cardiac output and perfusion, it does not directly reflect the patient's oxygenation and ventilation status, which are critical in the context of respiratory failure.
Choice C reason: Heart rate monitoring is useful for assessing the patient's hemodynamic status and detecting potential arrhythmias or other cardiac issues. However, it does not provide specific information about the effectiveness of treatments for acute respiratory failure. Heart rate alone cannot indicate how well the lungs are functioning or how effectively mechanical ventilation is supporting the patient's respiratory needs.
Choice D reason: Capillary refill is a simple and quick assessment of peripheral perfusion, indicating how well the blood is flowing to the extremities. While it can provide some information about the patient's circulatory status, it is not a reliable method for determining the effectiveness of treatments in acute respiratory failure. Capillary refill does not provide direct information about oxygenation, ventilation, or the overall respiratory status of the patient.
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