ch61.doc

[Osborn] chapter 61

Learning Outcomes [Number and Title ]Learning Outcome 1 Compare and contrast the etiologies of anaphylactic,

cardiogenic, hypovolemic, neurogenic, and septic shock.Learning Outcome 2 Describe the cellular alterations that occur in shock.Learning Outcome 3 Describe the body’s response to shock.

Learning Outcome 4 Identify the factors that place a patient at risk of developing shock.

Learning Outcome 5 Discuss the emergency care of the patient in shock, including identification of the underlying cause; management of the patient’s airway, breathing, and circulation; and selected pharmacologic interventions.

Learning Outcome 6 Describe the acute care of the patient in shock, including oxygen management, circulatory management, nutritional management, skin care, and pain and sedation management.

Learning Outcome 7 Compare and contrast systemic inflammatory response syndrome (SIRS), sepsis, and severe sepsis based on the definition used by the American College of Chest Physicians/Society of Critical Care Medicine.

Learning Outcome 8 Prioritize the treatment of the patient with SIRS and identify strategies to prevent the development of SIRS.

Learning Outcome 9 Understand the etiologies, epidemiology, and management of multiple organ dysfunction syndrome (MODS) as an end result of shock and severe sepsis.

Learning Outcome 10 Prioritize the treatment of the patient with MODS and identify strategies to prevent the development of MODS.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for PracticeCopyright 2010 by Pearson Education, Inc.

1. When caring for a group of clients, the nurse observes which of the following clients for signs and symptoms of hemorrhagic shock?

Client 6 hours postmastectomy Client who had a DVT after a surgical procedure 2 years earlier Client sustaining a transmural myocardial infarction 2 days ago Client with coronary atherosclerosis who takes 81 mg of aspirin daily

Correct Answer: Client 6 hours postmastectomy

Rationale: Postoperative clients are at risk for hemorrhage; mastectomy clients typically have drains whose output should be carefully documented. A past history of DVT is not pertinent to hemorrhage, as DVT is caused by a clot. A large myocardial infarction may lead to cardiogenic shock, not hemorrhage. The antiplatelet properties of aspirin may predispose to bleeding; however, there is no indication of trauma or bleeding.

Cognitive Level: AnalysisNursing Process: PlanningClient Need: Physiological IntegrityLO: 1


2. The nurse is caring for a client with papillary muscle rupture. When assessing the client, the nurse is alert to the development of symptoms related to _________ shock?

1. Cardiogenic2. Anaphylactic3. Neurogenic4. Septic

Correct Answer: Cardiogenic

Rationale: The papillary muscle holds the valves in place and may be damaged during MI, the most common reason for cardiogenic shock. Anaphylactic shock develops from hypersensitivity reactions. Neurogenic shock results from spinal cord injury or vasodilatation below the level of spinal anesthesia, and septic shock results from overwhelming infection.

Cognitive Level: ApplicationNursing Process: AssessmentClient need Category: Physiological IntegrityLO: 1


3. The nurse is caring for a client with endocarditis who is receiving penicillin. The nurse should be particularly attentive to recognize early symptoms of which of the following types of shock?

1. Anaphylactic2. Cardiogenic3. Hypovolemic4. Septic

Correct Answer: Anaphylactic

Rationale: A hypersensitivity to medications, particularly penicillins, may occur at any time during initial or subsequent treatments with the drug. Cardiogenic shock results from loss of pumping ability due to damage to the left ventricle such as after MI. Hypovolemic shock results from decreased vascular fluid volume. Septic shock results from overwhelming infections and the SIRS.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological Integrity LO: 1


4. When caring for a client in shock, the nurse recognizes that consequences of decreased blood flow to the kidney will result in:

1. Azotemia.2. Elevated ammonia level.3. Hypokalemia.4. Hyperglycemia.

Correct Answer: Azotemia.

Rationale: Impaired tissue perfusion to the kidney will result in decreased perfusion and build up of nitrogenous wastes, or azotemia. Increased ammonia levels result from decreased perfusion to the liver. Hypokalemia does not typically appear in a shock state with metabolic acidosis; hyperkalemia may be present. Hyperglycemia is related to stress response and catecholamine release, not poor renal tissue perfusion.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological IntegrityLO: 2


5. The nurse is caring for a client who has developed septic shock related to cancer chemotherapy. The nurse recognizes changes in mental status most likely result from:

1. Decreased tissue oxygenation.2. Metastasis of underlying cancer.3. Anxiety about and fear of death.4. A result of chemotherapy.

Correct Answer: Decreased tissue oxygenation.

Rationale: Clients at risk for septic shock include those who are immunosuppressed, have invasive technology, or infections. Metastasis to the brain may cause confusion, but not sepsis. Anxiety and fear may lead to confusion, but not sepsis. “Chemo brain” has been documented as a cause of confusion, but not sepsis.



6. The nurse is evaluating acid−base status in a client with septic shock. Which of the following alterations is anticipated?

1. HCO3 of 10 mEq/L2. pH of 7.463. pCO2 of 35 mm HG4. pO2 of 77 mm HG

Correct Answer: HCO3 of 10 mEq/L

Rationale: Septic shock results in lactic acidosis secondary to tissue hypoxia, which is manifested in a decreased bicarbonate level. A pH of 7.46 is normal. A pCO2 of 35 mm is normal. A pO2 of >75−80 is normal.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 2


7. The family of a client in shock asks why the client’s hands are cold. The nurse’s best response is which of the following?

1. “Blood vessels constrict in shock, which takes the blood away from hands and feet.”

2. “We keep the intensive care unit cool to reduce clients’ metabolic rate.”3. “Your family member has developed a fever and chills.”4. “This happens frequently to clients in shock states.”

Correct Answer: “Blood vessels constrict in shock, which takes the blood away from hands and feet.”

Rationale: Vasoconstriction results from catecholamine release, which is a compensatory mechanism in shock. Cooling measures are used in shock for fever; the ICU is not purposefully chilled. There is no indication that the client has developed fever and chills. Stating that cold hands happen frequently does not answer the family member’s question.

Cognitive Level: ApplicationNursing Process: ImplementationPhysiological IntegrityClient Need:LO: 3


8. The nurse anticipates that catecholamine release in shock may result in which of the following?

1. Hyperglycemia2. Bradycardia3. Pinpoint pupils4. Thirst

Correct Answer: Hyperglycemia

Rationale: Catecholamine release causes breakdown of glycogen to glucose, leading to hyperglycemia. Bradycardia is not a consequence of catecholamine release; tachycardia is. Pinpoint pupils are not a result of catecholamine release; mydriasis is. Thirst is a symptom of hypovolemic shock; it is not specific to catecholamine release.

Cognitive Level: ApplicationNursing Process: AssessmentPhysiological IntegrityClient Need:LO: 3


9. When assessing a client in shock who takes a beta adrenergic blocker, the nurse recognizes that which of the following responses to shock may be altered?

1. Tachycardia2. Hypotension3. Bowel sound4. Cyanosis

Correct Answer: Tachycardia

Rationale: Beta adrenergic blockers inhibit the sympathetic nervous system, causing bradycardia. Hypotension will still occur with beta-blocker therapy, as the therapeutic effect of a beta blocker is to reduce blood pressure. Beta-blockers may cause constipation; decreased bowel sounds are expected in shock states. Cyanosis will still occur in a shock state, as beta-blockers do not interfere with symptoms of poor oxygenation.



10. The nurse is evaluating the clients in an intensive care unit for risk for sepsis and septic shock. Clients at risk for sepsis include the client:

Select all that apply.

1. From a nursing home with a stage 4 pressure ulcer. 2. With rheumatoid arthritis taking methotrexate. 3. With aplastic anemia.4. With blunt trauma spinal cord injury.5. With ruptured viscus vomiting bright red blood.

Correct Answer: 1. From a nursing home with a stage 4 pressure ulcer. 2. With rheumatoid arthritis taking methotrexate. 3. With aplastic anemia.

Rationale: From a nursing home with stage 4 pressure ulcer. Breaches in skin integrity such as pressure ulcers are risks for sepsis and septic shock. With rheumatoid arthritis taking methotrexate. Clients such as those taking methotrexate for chemotherapy or immune modulation are at risk for sepsis and septic shock. With aplastic anemia. Aplastic anemia results in suppression of all cellular elements of the bone marrow, including WBCs, which puts the client at risk for infection and sepsis. With blunt trauma spinal cord injury. Blunt spinal cord injury may lead to spinal or neurogenic shock. With ruptured viscus vomiting bright red blood. Fluid-volume deficit secondary to hematemesis may lead to hypovolemic shock.



11. When caring for a group of critically ill clients, the nurse recognizes that which of the following patients has risk for increased mortality from sepsis?

1. A 20-year-old student with diabetes 2. A 32-year-old accountant with a head cold3. A 60-year-old homemaker4. A 40-year-old with hyperparathyroidism

Correct Answer: A 20-year-old student with diabetes

Diabetes increases the risk of death from sepsis, as hyperglycemia promotes inflammation and increases the risk of ODS and death. Others at risk are those of advanced age, patients with cancers, and the immunosuppressed client. A head cold, a homemaker, and hyperparathyroidism do not have the same risks for death as the clients previously described.



12. The nurse is caring for a group of clients in a critical care unit. Which of the following clients does the nurse identify as at risk for hypovolemic shock?


1. Client with ruptured abdominal aortic aneurysm2. Client with cirrhosis, ascites, and anasarca3. Client in a multivehicle collision4. Client sustaining a myocardial infarction5. Client with systemic lupus erythematosus

Correct Answer: 1. Client with ruptured abdominal aortic aneurysm2. Client with cirrhosis, ascites, and anasarca3. Client in a multivehicle collision

Rationale: Client with ruptured abdominal aortic aneurysm. Clients at risk for hypovolemic shock include those with hemorrhage and GI bleeding. Client with cirrhosis, ascites, and anasarca. Clients at risk for hypovolemic shock include those with hemorrhage, GI bleeding, third spacing, and unreplaced fluid loss. Client in a multivehicle collision. Clients at risk for hypovolemic shock include those with abdominal injury or trauma. Client sustaining a myocardial infarction. A myocardial infarction may lead to cardiogenic, not hypovolemic, shock. Client with systemic lupus erythematosus. A client treated for lupus typically takes immunosuppressing drugs such as corticosteroids, placing the client at risk for septic shock.



13. The nurse is caring for an 80-year-old client with septic shock admitted from a nursing home earlier today. Which of the following should the nurse consider the most likely source of the sepsis?

1. An indwelling Foley catheter inserted by nursing home personnel2. An intravenous catheter inserted in the field3. A red, flat rash in the perineal area4. Exposure to the client’s daughter who is receiving chemotherapy

Correct Answer: An indwelling Foley catheter inserted by nursing home personnel

Rationale: A major cause of sepsis is indwelling urinary catheters. An intravenous catheter inserted in the field would not cause sepsis if just inserted. A perineal rash without open skin will not contribute to sepsis. The client’s daughter who receives chemotherapy is at risk for infection and sepsis, not the client.



14. When caring for a client with suspected cardiogenic shock, which of the following would be most helpful in confirming the underlying cause?

1. Monitoring cardiac enzymes2. Monitoring mean arterial pressure using an intra-arterial line3. Measuring the central venous pressure4. Monitoring pulmonary artery pressure

Correct Answer: Monitoring cardiac enzymes

Rationale: Measuring cardiac enzymes will determine the presence of myocardial infarction, the major cause of cardiogenic shock. Arterial pressure monitoring is useful in all shock states, but is not specific to cardiogenic shock. Central venous pressure assesses fluid volume, and is not specific to cardiogenic shock. Pulmonary artery pressures assess for pulmonary artery hypertension and fluid volume, and are not specific to cardiogenic shock.



15. When caring for a patient who was stabbed in the abdomen, the nurse recognizes that 2 liters of fluid given over the last hour have been ineffective when the patient displays which of the following?

1. Heart rate 142 and regular2. Blood pressure 94/503. Urine output of 45 ml for this hour4. Patient complains of abdominal pain

Correct Answer: Heart rate 142 and regular

Rationale: Evidence of successful fluid resuscitation includes heart rate <110, presence and strength of peripheral pulses, restoration of BP to >90 mmHG systolic, urine output of at least 30 ml/hour or 0.4 to 1.0 ml/kg/hour. Presence of abdominal pain is not an outcome criterion for shock.

Cognitive Level: AnalysisNursing Process: EvaluationClient Need: Physiological Integrity LO: 5


16. When admitting a client with septic shock, the nurse focuses on which of the following potential causes in the patient’s history?

1. Client has received a liver transplant 3 months prior2. Client underwent cholecystectomy last year3. Client has a history of kidney stones4. Client states he had a heart attack last month

Rationale: The client who has received an organ transplant must take immunosuppressant drugs for the life of the transplant, which places the individual at risk for sepsis. A client who has recovered from cholecystectomy, kidney stones, or MI is not at risk for sepsis.



17. In order to protect the airway in a client with a Glasgow Coma Scale score of 3, the nurse collaborates with the health care team to assist with which of the following?

1. Endotracheal intubation2. Assessment of bowel sounds3. Monitoring oxygen saturation4. Questioning the client regarding difficulty breathing

Correct Answer: Endotracheal intubation

Rationale: A Glasgow Coma Scale score of 3 indicates a very decreased level of consciousness; the priority is to protect the airway. Bowel sounds may be absent in shock; the ABCs are addressed first. Questioning regarding difficulty breathing is not done because the client is not verbal with a Glasgow Coma Scale score of 3.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological Integrity LO: 6


18. When caring for the client in septic shock, the nurse recognizes fluid replacement is inadequate when which of the following is noted?

1. Urine output 10 milliliters for the last hour2. Pulse rate of 100 beats per minute3. MAP 754. Central venous pressure is 5 mmHG

Correct Answer: Urine output 10 milliliters for the last hour

Rationale: Adequate blood flow to the kidneys is measured by urine output of 0.5 ml/kg/hour. A heart rate of 100 is considered acceptable in shock. MAP should be kept > 65 mmHG. Normal CVP is 4 to 12.

Cognitive Level: AnalysisNursing Process: EvaluationClient Need: Physiological IntegrityLO: 6


19. A client with hemorrhagic shock is receiving norepinephrine (Levophed) by continuous infusion. Which of the following outcomes is anticipated?

1. Blood pressure of 100/542. Reduction in bleeding3. Reduced apical heart rate4. Decline in cardiac enzymes

Correct Answer: Blood pressure of 100/54

Rationale: Norpinephrine (Levophed) is a catecholamine used in shock to raise blood pressure. Reduction in bleeding is not the intended effect; bleeding may actually increase as blood pressure is restored. The apical pulse would increase related to the catecholamine effects; therefore reduced heart rate is not the intended outcome. A decline in cardiac enzymes is not anticipated, as norepinephrine increases afterload and cardiac workload; this is not the intended effect.

Cognitive Level: ApplicationNursing Process: EvaluationClient Need: Physiological IntegrityLO: 7


20. The nurse is caring for a client with septic shock. Which of the following findings is present in septic shock?

1. Patient with infection, blood pressure 84/52 after 4 liters of saline2. Patient with burns over 40% of the body and febrile3. A patient with WBC count of 22,000 and fever4. Patient with respiratory failure and community-acquired pneumonia

Correct Answer: Patient with infection, blood pressure 84/52 after 4 liters of saline

Rationale: By definition, septic shock exists when sepsis is refractory to fluid resuscitation. A burn injury with fever does not meet the criteria for severe sepsis. A high WBC count and fever may be present in an uncomplicated infection. Respiratory failure secondary to pneumonia does not indicate presence of severe sepsis with shock.



21. When caring for a client with sepsis, the nurse recognizes that which of the following indicates a progression to severe sepsis?


1. Client requires intubation and mechanical ventilation for respiratory failure2. Blood pressure of 80/42 after 4 liters of fluid have been given 3. Hematuria, epistaxis, and oozing from central venous catheter site4. WBC count of 4000 cells/cubic millimeter5. Urine output of 40 to 60 milliliters per hour

Correct Answer: 1. Client requires intubation and mechanical ventilation for respiratory failure2. Blood pressure of 80/42 after 4 liters of fluid have been given 3. Hematuria, epistaxis, and oozing from central venous catheter site

Rationale: Client requires intubation and mechanical ventilation for respiratory failure. Severe sepsis is defined as the presence SIRS with hypotension/shock, a confirmed infection, and single or multiple organ failure. Inability to manage maintenance respiratory functions is consistent with a worsening condition. Blood pressure of 80/42 after 4 liters of fluid have been given. Continuing hypotension after the administration of treatment indicates a continuation of responses. Hematuria, epistaxis, and oozing from central venous catheter site. Coagulopathy may be a manifestation of worsening sepsis. WBC count of 4000 cells/cubic millimeter. A WBC count of 4000 is normal. Urine output of 40 to 60 milliliters per hour. Urine output of 40 to 60 ml/hour (or 0.5 ml/kg/hour) is normal. Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 7


21. The nurse is reviewing the diagnostic tests for a client with an infection. Which of the following indicates the presence of sepsis?

1. Decreased activated protein C2. Potassium 2.9 mEq/L3. WBCs 5000 cells/cubic mm4. Hemoglobin 8.5 gm/dL/Hematocrit 25.2%

Correct Answer: Decreased activated protein C

Rationale: A decreased activated protein C level is associated with sepsis, coagulopathy, MODS, and increased mortality. Potassium levels are not specific to the diagnosis of sepsis. WBC count of 5000 is normal. A low H & H indicates hemorrhage or destruction of cells. Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological Integrity


22. The nurse plans to administer fluid to a client with SIRS and hypotension. Which of the following orders should the nurse anticipate to prevent progression of shock?

1. Administer 1000 ml of lactated ringers over the next 2 hours.2. Infuse 20 ml of D5½ normal saline solution per hour.3. Give 3% saline at a rate of 20 ml/hour.4. Administer D5W at a rate of 100 ml/hour.

Correct Answer: Administer 1000 ml of lactated ringers over the next 2 hours.

Rationale: Isotonic solutions, such as normal saline or lactated ringers, should be administered at a rate of 20 ml/kg/hr and increased to maintain urine output of 0.5 ml/kg/hr. D5½ normal saline is a slightly hypertonic fluid; the rate of infusion is too low for patients in shock. Three percent saline is hypertonic. D5W is a hypotonic solution.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Physiological IntegrityLO: 8


23. The critical care nurse is delivering a peer lecture on guidelines for the management of SIRS and severe sepsis. Current evidence suggests which of the following will improve outcome in septic shock?

1. Maintain blood glucose between 110 and 134 mg/dL2. Antibiotic therapy initiated prior to end of shift3. Mechanical ventilation with tidal volume of 10 ml/kg4. Bicarbonate used for pH of 7.30

Correct Answer: Maintain blood glucose between 110 and 134 mg/dL

Rationale: Current evidence indicates that maintaining blood glucose <150 mg/dL improves lipid levels and has anti-inflammatory and anticoagulant properties, improving chances of survival. Antibiotic therapy should be initiated within the first hour of identifying sepsis. Mechanical ventilation with tidal volumes of 4 to 6 liters/kg of normal body weight improves outcome. Bicarbonate is not routinely used for acidosis.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Physiological Integrity LO: 8


24. When caring for the client in septic shock, the nurse recognizes that current evidence supports use of which of the following interventions to improve outcome?

1. Mechanical ventilation with a tidal volume of 4 to 6 ml/kg2. Vasopressin instead of dopamine for hypotension3. Limiting fluids to 3 liters per day4. Positioning the client in high Fowler’s position

Rationale: Current evidence suggests that maintaining mechanical ventilation with lower-than-traditional tidal volumes of 4 to 6 ml/kg results in improved outcome. Vasopressin is indicated when other pressors have failed to restore blood pressure. Fluid restriction is indicated in cardiogenic shock. Positioning the client flat may be necessary to maintain MAP.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological IntegrityLO: 8


25. Which of the following interventions will reduce metabolic demands in a client with multiple organ dysfunction syndrome?

1. Administer antipyretics for fever >101 degrees.2. Place the client on a high-fat diet to increase energy.3. Provide skin care and positioning to prevent breakdown.4. Use meticulous hand hygiene and aseptic technique for procedures.

Correct Answer: Administer antipyretics for fever >101 degrees.

Rationale: Reducing fever will decrease metabolic rate and oxygen demand. A high-fat diet is not indicated in shock; however, attention to nutrition and adequate calories is necessary. Skin care and positioning are essential to prevent breakdown and further entry of bacteria into the body, but will not reduce oxygen demands. Asepsis and hand washing are essential to prevent further infection, but will not reduce oxygen demand.



26. The nurse is caring for a client with septic shock and MODS. The client’s family member tearfully tells the nurse, “The doctor said my mother’s organs are shutting down. How did that happen?” Which of the following is the best response?

1. “Deprivation of oxygen during shock causes organs to fail to function properly.”2. “The infection attacks and destroys each organ, causing them to fail.”3. “Fever damages the brain, which controls all organs.”4. “The stress of illness has overwhelmed your loved one.”

Correct Answer: “Deprivation of oxygen during shock causes organs to fail to function properly.”

Rationale: The cascade of events in shock states results in inadequate tissue perfusion and hypoxia leading to organ failure. Infection does not strike each organ; rather, an inflammatory process begins a cascade of events impairing tissue perfusion that causes organs to fail. Fever may cause brain damage if exceedingly high and increase metabolic demand, increasing oxygen demand, but it is not the primary reason for MODS. The stress response is activated as a compensatory mechanism; however, it is not the primary reason for MODS.



27. When planning care for a client with MODS secondary to septic shock, the nurse suggests which of the following to the provider, as evidence shows a reduction in mortality?

1. Recombinant activated protein C (xigris)2. Heparin3. Packed red blood cell transfusion4. Dobutamine (Dobutrex)

Correct Answer: Recombinant activated protein C (xigris)

Rationale: Recombinant activated protein C (xigris) is indicated for clients with a high risk of death, such as organ failure. Heparin is not typically used in the treatment of septic shock. Packed red blood cell transfusions are used to increase the oxygen-carrying capacity of the blood, such as after hemorrhage. Blood transfusions do not improve survival in septic shock. Dobutamine is added in septic shock to improve cardiac output, but has not been shown to improve survival.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Physiological IntegrityLO: 9


28. Which of the following is the priority for a client with MODS and adult respiratory distress syndrome (ARDS)?

1. Maintain oxygen saturation 88% to 92%.2. Provide mechanical ventilation with tidal volume of 10 ml/kg.3. Administer sodium bicarbonate for pH of 7.31.4. Provide frequent mouth care to prevent ventilator-associated pneumonia.

Correct Answer: Maintain oxygen saturation 88% to 92%.

Rationale: The goal of therapy in shock is to maintain tissue perfusion with oxygen saturation 88% to 92% or more. Mechanical ventilation is provided with low tidal volumes of 4 to 6 ml/kg. Bicarbonate is given for pH<7.1. Frequent mouth care is an intervention, but not a higher priority than airway management.



29. The nurse is caring for a client with MODS secondary to septic shock whose urine output was 10 ml for the last 2 hours. Temperature is 97 degrees, pulse is 124 and thready, and BP is 88/48. Which of the following orders is the priority at this time?

1. Administer isotonic fluids at 20 ml/kg/hr.2. Draw blood for BUN and creatinine.3. Place the client in a kinetic bed.4. Place the client on a warming blanket.

Correct Answer: Administer isotonic fluids at 20 ml/kg/hr.

Rationale: The client has entered the cold or hypodynamic phase of shock characterized by vasodilation and profound hypotension. Fluids are indicated to improve blood pressure and blood flow through the kidney. BUN and creatinine may be evaluated to determine the consequence of renal blood flow, but this is done after the ABCs have been addressed. A kinetic bed will decrease pressure on the skin and prevent breakdown secondary to decreased tissue perfusion, but is performed after the ABCs are addressed. A low body temperature in the cold or hypodynamic phase is expected; warming may cause vasodilation and lowered blood pressure. Treating the underlying cause of hypoperfusion to the kidneys is indicated.



30. Which of the following should take priority in a patient with MODS secondary to severe sepsis?

1. pO2 of 54 mmHg2. WBC count of 28,000 cell/cubic mm3. Serum lactate level is 2 mmol/L4. Blood glucose of 245 mg/dL

Correct Answer: pO2of 54 mmHg

Rationale: The nurse follows the ABCs for priority; a pO2 of 54 mmHg reflects hypoxemia, the priority. A WBC count of 28,000 cells indicates infection; antibiotics are begun within the first hour of identifying severe sepsis, but not before airway and breathing are restored. A serum lactate level of 2 mmol/L is normal. Blood glucose level should be controlled, but not before the airway and breathing are corrected.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological Integrity

LO: 10


ch61.doc

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