Which intervention will the nurse include in the plan of care for ...

[OSWALD]

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
 
  a. Check temperature every 2 hours.
  b. Monitor breath sounds frequently.
  c. Maintain patient in supine position.
  d. Assess skin for flushing and itching.

Question 2

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication?
 
  a. 5 human albumin
  b. Furosemide (Lasix) IV
  c. Epinephrine (Adrenalin) drip
  d. Hydrocortisone (Solu-Cortef)

[shayla]

Answer to Question 1

ANS: B
Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Answer to Question 2

ANS: B
The PAWP indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. 5 human albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.