The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply.

Drop in systolic blood pressure of 40 mm Hg from baselines

Hypotension that responds to bolus fluid resuscitation

Exaggerated response to vasoactive medications

Serum lactate >4 mmol/L

Mean arterial pressure (MAP) of <65 mm Hg

Answer and Explanation

Correct Answer : A,D,E

Rationale:
A. Drop in systolic blood pressure of 40 mm Hg from baseline is correct because a significant decrease in blood pressure indicates impaired perfusion to vital organs, which is a hallmark of acute organ dysfunction in shock.

B. Hypotension that responds to bolus fluid resuscitation is incorrect because fluid-responsive hypotension suggests early or compensatory shock. Persistent hypotension or inadequate perfusion despite fluids is more indicative of organ dysfunction.

C. Exaggerated response to vasoactive medications is incorrect because exaggerated responses are not typical markers of organ dysfunction. In shock with organ dysfunction, patients often show refractory hypotension despite vasoactive medications, not an exaggerated effect.

D. Serum lactate >4 mmol/L is correct because elevated lactate indicates tissue hypoperfusion and anaerobic metabolism, which is a key marker of organ dysfunction and severe shock.

E. Mean arterial pressure (MAP) of <65 mm Hg is correct because MAP <65 mm Hg is associated with inadequate perfusion of vital organs, contributing to acute organ dysfunction.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. The 22-year-old who is crying after visitors left is experiencing emotional and psychological distress. While psychosocial support is an important component of burn care, this situation does not represent an immediate threat to life. Emotional needs can be addressed after physiologic priorities are managed.

B. The 34-year-old who recently returned from skin-graft surgery and reports severe pain requires prompt pain management. Uncontrolled pain can cause stress responses and delayed healing, but pain alone, in the presence of stable vital signs, is not immediately life-threatening and does not take priority over signs of systemic instability.

C. The 45-year-old with deep partial-thickness burns, a fever of 102.6°F, and hypotension with a blood pressure of 98/46 is exhibiting signs suggestive of sepsis or early septic shock. Burn patients are highly susceptible to infection due to loss of skin integrity and impaired immune response. The combination of fever and low blood pressure indicates systemic infection with compromised perfusion, which can rapidly progress to multi-organ failure if not treated immediately. This client requires urgent assessment and intervention, including hemodynamic support and evaluation for infection.

D. The 57-year-old with electrical burns and a potassium level of 5.0 mEq/L has a value at the upper limit of normal. Electrical burns increase the risk for hyperkalemia due to muscle damage, so this finding requires close monitoring, but it is not immediately life-threatening at this level and does not take priority over hypotension and fever.

A. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months C. Promoting communication with the patient and family along with addressing end-of-life issues D. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

Correct Answer is C

Explanation

Rationale:
A. Encouraging the family to stay hopeful and suggesting that the prognosis is good is incorrect because MODS carries a high mortality rate, especially when multiple organs are involved. Providing false reassurance is inappropriate and can damage trust.

B. Encouraging the family to leave the hospital and take time for themselves is incorrect because while self-care is important, family presence and involvement in care and decision-making are crucial, particularly in end-of-life or critical situations.

C. Promoting communication with the patient and family along with addressing end-of-life issues is correct because MODS is often progressive and life-threatening, and families benefit from honest communication, emotional support, and guidance in end-of-life decision-making. This approach respects patient and family needs and aligns care with their values and wishes.

D. Discussing organ donation on multiple occasions is incorrect because repeated discussions can be distressing and may not be appropriate until the patient’s prognosis is clear or death is imminent. Timing and sensitivity are critical when introducing organ donation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You have just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention?

Correct Answer is C

Explanation

The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions?

Correct Answer is C

Explanation

Cefazolin sodium 250 mg IV every 8 hours is ordered for your patient. You are to reconstitute with 2.5 ml sterile normal saline. After reconstitution the vial contains 225 mg/ml. How many ml will you administer per dose?

The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply.

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36/min. What is the priority intervention?

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

A nurse in an emergency room is caring for the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?