Chapter 66 Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
The nurse is caring for a patient in a shock state. After reviewing the daily orders for the patient, the nurse notes that electrolyte levels have not been ordered. For which critical electrolyte imbalance should the nurse closely monitor this patient?
Hypokalemia as a result of the body compensating for renal hypoperfusion by initiating release of aldosterone
The nurse is caring for a patient in a shock state and is planning care related to decreased peripheral tissue perfusion. Which interventions should the nurse be prepared to implement?
Continuous use of a pressure-relieving mattress
Turning the patient every hour according to a turning schedule
Planning for bathing when the patient is most rested to decrease oxygen demand
The nurse is preparing a care plan for a patient in a shock state. What actions should be included for this patient?
Monitor intake, output, and daily weight.
Reduce noise and light in the patient’s room
Adhere strictly to handwashing and minimize invasive procedures
Auscultate bowel sounds and assess for abdominal distention at least every 4 hours
The nurse is caring for an intubated patient who is experiencing alternating levels of consciousness. How should the nurse approach caring for this patient?
Explain all care to the patient in simple terms.
Ensure that the plan of care is communicated when the patient is most alert.
Keep paper and pencil in the room for the patient to use when he or she is awake.
The nurse is caring for an older adult patient in an intensive care unit (ICU) who is in a shock state. The patient has many caring family members who want to understand and assist in providing care to the patient. Which nursing intervention should the nurse take to best facilitate this family’s desire?
A nurse is being orientated to the intensive care unit (ICU) and asks, “Why is so much emphasis put on helping the family when we have such sick patients?” Which responses from the nurse are appropriate?
“Empathizing with the family helps the family support the patient.”
“Families of critically ill patients are also experiencing a crisis.”
“Family members are often away from home and also need our support.”
“Family members can provide help to orient the patient and reduce agitation.”
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