Correct answer—B. Rationales: The standard therapy for a hemodynamically unstable client in hemorrhagic hypovolemic shock is rapid infusion of crystalloid fluid at 20 to 40 mL/kg. The minimal rate of fluid replacement, 5 to 10 mL/kg, may not be sufficient to raise the circulating volume. A rate of 80 to 300 mL/kg may result in dilution of the remaining red blood cell mass, platelets, and coagulation factor. Clot formation in the injured vessels may be disrupted, and homeostasis of the injured site won’t be maintained.

Nursing process step: Intervention

Correct answer—D. Rationales: The initial assessment of a client in shock must be rapid and begins with the primary survey. The airway, if not patent, must be opened while maintaining cervical spine stabilization. Breathing effectiveness needs to be assessed, and supplemental oxygen should be administered in the most appropriate route based on the client’s condition. Assessment of circulation should be done by noting the client’s skin temperature, moisture, and color. Capillary refill time in an adult (normal, 2 to 3 seconds; delayed, more than 3 seconds) is of questionable value but may still be included during the assessment as a baseline parameter. The client’s level of consciousness must be evaluated next because cerebral perfusion may be affected by low-perfusion blood flow. If circulation is compromised, two I.V. lines with 14G to 16G catheters should be started with warmed normal saline or lactated Ringer’s solution. Pupillary response assessment is performed to determine the equality of pupil size and response to light stimulation. The assessment is organized to identify and correct the most life-threatening conditions first.

Nursing process step: Assessment

Correct answer—C. Rationales: The client is hypotensive with a narrow pulse pressure, tachycardia, and altered level of consciousness. These signs and symptoms indicate that the client is in a compensatory phase of a hypovolemic shock condition. The mechanism of injury (unrestrained driver in a motor vehicle accident) suggests blunt trauma to the abdomen. The most common form of shock in trauma clients is hypovolemic shock. Cardiogenic shock is typically caused by myocardial infarction. Septic shock is most commonly caused by gram-negative and gram-positive bacteria. Neurogenic shock results from a severe brain stem injury at the level of the medulla, an injury to the spinal cord, or spinal anesthesia. A client with neurogenic shock has a different presentation than one with hypovolemic shock. Signs and symptoms of neurogenic shock include peripheral vasodilation and severe hypotension from loss of sympathetic tone. On assessment, the client is hypotensive with warm, flushed skin.

Nursing process step: Assessment

Correct answer—B. Rationales: An initial serum lactate value greater than 4 mmol/L is associated with increased client mortality. Serum lactate levels have been used for decades to identify and manage clients with progressive circulatory dysfunction secondary to sepsis. Successful hemodynamic resuscitation and continued monitoring are key components of the management of sepsis in the emergency department. An ABG pH of 7.35 is within normal limits. A CVP of 4 cm H₂O pressure is within normal limits; however, current research demonstrates that CVP isn’t an accurate measure of fluid resuscitation. Hypotension is a symptom of septic shock and isn’t the best indicator of the prognosis.

Nursing process step: Analysis

Correct answer—A. Rationales: Normal CVP readings range from 4 to 10 cm H₂O. A reading above 10 cm H₂O indicate volume overload; readings below 4 cm H₂O identify a deficient fluid volume. Because the client is fluid deficient, a fluid bolus is appropriate and reducing the fluids is inappropriate. Dopamine should be administered after preexisting hypovolemia has been corrected. CVP is an unreliable estimate of what’s happening to intravascular volume even in the healthiest client and the most stable situations.

Nursing process step: Analysis

Correct answer—A. Rationales: Hypovolemic shock is the most common form of shock in trauma clients. It occurs as a result of inadequate intravascular volume from the loss or redistribution of whole blood, plasma, or other body fluids. Hypovolemic shock is commonly caused by the loss of whole blood (hemorrhage). Additional causes are dehydration from body fluid loss and displaced fluid, as seen in thermal injuries. Cardiogenic shock is caused by myocardial infarction. Neurogenic shock is caused by loss of sympathetic tone brought on by spinal anesthesia or injury to the spinal cord. Anaphylactic shock is most commonly caused by an acute allergic reaction.

Nursing process step: Assessment

Correct answer—C. Rationales: Fluid volume replacement must be calculated to the child’s weight to avoid overhydration. Initial fluid bolus is administered at 20 mL/kg, followed by another 20 mL/kg bolus if there’s no improvement in volume status. All other options are incorrect.

Nursing process step: Intervention

Correct answer—D. Rationales: Prehospital providers rarely use the PASG to control hemorrhage and support blood pressure; however, when it is used, inflation of the device causes tamponade of soft-tissue hemorrhage and raises blood pressure by increasing systemic vascular resistance. The PASG is contraindicated with a right-sided tension pneumothorax because it further elevates venous pressure associated with the tension pneumothorax. The PASG is also useful for unstable pelvic and femur fractures. In these cases, the garment stabilizes the fractures and tamponades retroperitoneal hemorrhage. Clients in anaphylactic shock may benefit from the PASG because it increases preload and enhances cardiac output.

Nursing process step: Intervention

Correct answer—C. Rationales: Alpha-adrenergic receptor stimulation results in vasoconstriction of the vascular beds. This occurs as a compensatory mechanism to enhance the central circulation by increasing diastolic blood pressure and maintaining systolic blood pressure. Beta-adrenergic receptor stimulation results in bronchodilation and postcapillary vasodilation. Options B and D are incorrect.

Nursing process step: Assessment

Correct answer—D. Rationales: The most common organism responsible for septic shock is gram-negative bacteria, which releases endotoxins that activate various hormone and chemical mediators. Other causative organisms of septic shock are gram-positive bacteria, fungi, viruses, and rickettsiae. The client who received a 3-cm laceration on the hand while washing dishes has the lowest probability of developing septic shock because the injury occurred in a clean environment. Populations at risk for developing septic shock are the very young, the very old, multiple-injury clients, debilitated individuals, and immunosuppressed clients.

Nursing process step: Assessment

Correct answer—C. Rationales: In addition to whole blood or packed RBCs, fresh frozen plasma or platelets should be replaced in a client with hemorrhagic shock. RBCs have minimal clotting factors and platelets available. To decrease the probability of the client developing coagulopathy deficits, 1 to 2 units of fresh frozen plasma or platelets are commonly administered after the infusion of 5 units of blood. Albumin is administered to expand the plasma volume rapidly and may not be necessary as long as blood has been replaced. Dextran and washed RBCs aren’t clotting components.

Nursing process step: Intervention

Correct answer—C. Rationales: Direct pressure applied to the laceration is the most immediate nursing intervention to control bleeding. Applying a tourniquet above the injury may result in permanent damage to the circulatory and nervous pathways in the arm. Injecting epinephrine into the arm and suturing the wound are usually done by the medical staff.

Nursing process step: Implementation

Correct answer—A. Rationales: Cardiogenic shock occurs when the heart fails as a pump and results in reduced cardiac output. MI is the most common cause of cardiogenic shock. Myocardial contusion, cardiac temponade, and cardiac failure can also cause cardiogenic shock but they aren’t the most common cause.

Nursing process step: Assessment

Correct answer—C. Rationales: Distributive shock results from a disruption in the tone of blood vessels that leads to vasodilation and maldistribution of blood volume. Examples of distributive shock include neurogenic shock, septic shock, and anaphylactic shock. “Spinal shock” term used to describe the flexia and flaccidity associated with complete cord injuries. Cardiogenic shock occurs when the heart fails as a pump. Hypovolemic shock results from inadequate circulating volume.

Nursing process step: Analysis

Correct answer—C. Rationales: The client’s urine output is within the normal range (equal to or greater than 30 mL/hour). The client is therefore experiencing adequate renal perfusion and the I.V. fluids should be decreased. The nurse should continue to monitor the urine output to determine whether the client is perfusing the viscera. It isn’t necessary to infuse another 2 L of normal saline solution because the client has adequate urine output. It’s inappropriate to switch to D₅W.

Nursing process step: Evaluation

Correct answer—C. Rationales: The major clinical signs of neurogenic shock are hypotension and bradycardia. Clients are generally hypotensive with warm, dry skin. Cool, diaphoretic skin is more likely to be associated with shock from fluid loss. The loss of sympathetic tone may impair the ability to redirect blood flow from the periphery to the core circulation, leading to excessive heat loss and hypothermia. Bradycardia is a characteristic finding of neurogenic shock; however, it isn’t universally present.

Nursing process step: Assessment

Correct answer—B. Rationales: Injury to the cervical spinal cord affects the autonomic nervous system. Below the injury, the client will demonstrate blocking of sympathetic vasomotor regulation, resulting in extreme vasodilation and maldistribution of the circulating volume. Neurogenic shock occurs as a result of peripheral vasodilation with decreased venous return. The client’s skin is warm, dry, and flushed. The client is hypotensive and bradycardic. The other options don’t represent the client’s assessment findings.

Nursing process step: Assessment

Correct answer—C. Rationales: Distributive shock results when the blood volume remains the same but vasodilatation causes decreased systemic vascular resistance. The heart is able to pump less effectively in cardiogenic shock. Hypovolemic shock results from a significant loss of blood and fluids. Obstructive shock results from compression of great veins, aorta, pulmonary arteries, or the heart.

Nursing process step: Assessment

Correct answer—B. Rationales: The client has a right-sided tension pneumothorax, creating an obstruction due to increased intrathoracic pressure displacing the inferior vena cava and obstructing venous return to the right atrium. Preload is decreased, and the client’s vital signs exhibit a sympathetic response. Hypovolemic shock results in flat jugular veins from the low-volume state, and the trachea isn’t affected. Clients with septic shock don’t typically have alterations in the trachea, and jugular veins aren’t generally distended. Neurogenic shock results in bradycardia from the depressed sympathetic nervous system innervation.

Nursing process step: Assessment

Correct answer—B. Rationales: Early shock (class I) is characterized by normal or slightly increased pulse pressure and normal blood pressure. Narrowing pulse pressure is seen in class II shock when falling systolic pressure and rising diastolic pressure are seen. Sympathetic stimulation occurs as specialized cells in the carotid and aorta sense a decrease in oxygen and an increase in carbon dioxide in the circulating blood. Catecholamines are released to produce peripheral vasoconstriction and an increase in total peripheral resistance. This action results in an increase in diastolic pressure as a means of increasing preload and cardiac output. All other options are incorrect.

Nursing process step: Assessment

Correct answer—D. Rationales: Rapid I.V. infusion of a crystalloid can best be accomplished by using a large-bore short catheter. A large-bore long catheter and long I.V. tubing or extension sets increase the infusion time. A short I.V. pole doesn’t allow I.V. fluids to flow rapidly because of the decreased gravitational pull.

Nursing process step: Intervention

Correct answer—C. Rationales: Blood should be infused through an I.V. line with normal saline. Lactated Ringer’s solution contains enough ionized calcium (3 mEq/L) to overcome the anticoagulant effect of CPDA-1 and allow the development of small clots, which may precipitate in the I.V. line. Dextran and D₅W contain glucose, which causes clumping of the red cells in the tubing and results in swelling and hemolysis of the red blood cells. The blood should be administered through a filter. Although filters come in mesh and microaggregate types, the latter is preferred, especially when transfusing multiple units of blood.