Chapter 66 Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
A patient is being cared for in an intensive care unit. The nurse assesses the patient’s vital signs as follows: blood pressure, 88/56 mm Hg; heart rate, 126; respiratory rate, 28 breaths/min; temperature, 102.6° F (39.2° C). The patient is not oriented and is drowsy. What do these findings indicate?
The patient is in septic shock.
A patient is in the intensive care unit with shock that has progressed to systemic inflammatory response syndrome (SIRS). The nurse is monitoring the kidneys for any signs of organ dysfunction. Which findings indicate a progression to severe renal dysfunction?
- Urine specific gravity of 1.032
- Urine sodium level of 18 mEq/L
- Urine osmolality of 980 mOsm/kg
The nurse is monitoring a patient who remains in a shock state. The nurse anticipates that the laboratory results will indicate which abnormal findings?
- Hyperkalemia
- Metabolic acidosis
- Elevated lactate acid level
- Elevated liver enzyme levels
The nurse is caring for a patient who begins receiving an intravenous (IV) antibiotic. The patient has difficulty breathing, wheezing, chest pain, and anxiety. What is the nurse’s priority action?
Stop the IV infusion
The nurse is caring for a patient with an indwelling urinary catheter. The nurse has been taking measures to prevent infection but assesses early signs of a systemic infection. The nurse anticipates implementing which orders from the provider?
- A urine culture
- A blood culture
- Administer a broad-spectrum antibiotic
The nurse is caring for a critically ill, unstable patient who has systemic inflammatory response syndrome (SIRS) that is progressing to multiple organ dysfunction syndrome (MODS). Which interventions should the nurse anticipate?
- Enteral feedings
- Infusion of glucose and insulin
- Administration of loop diuretics
- Continuous electrocardiographic (ECG) monitoring
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