Free NCLEX Practice Questions.
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- Question 1 of 1
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully assess the client?Correct
Answer & Rationale:
Option 2 is Correct
Rationale: Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.Incorrect
Answer & Rationale:
Option 2 is Correct
Rationale: Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.
- Cardiogenic shock is failure of the heart to pump adequately, thereby reducing cardiac output and compromising tissue perfusion.
- Necrosis of more than 40% of the left ventricle occurs, usually as a result of occlusion of major coronary vessels.
- The goal of treatment is to maintain tissue oxygenation and perfusion and improve the pumping ability of the heart.
- Hypotension: BP lower than 90 mm Hg systolic or 30mmHg lower than the client’s baseline
- Urine output lower than 30 mL/hr
- Cold, clammy skin
- Poor peripheral pulses
- Pulmonary congestion
- Disorientation, restlessness, and confusion
- Continuing chest discomfort
- Administer morphine sulfate intravenously as prescribed to decrease pulmonary congestion and relieve pain.
- Administer oxygen as prescribed.
- Prepare for intubation andmechanical ventilation.
- Administer diuretics and nitrates as prescribed while monitoring the BP constantly.
- Administer vasopressors and positive inotropics as prescribed to maintain organ perfusion.
- Prepare the client for insertion of an intraaortic balloon pump, if prescribed, to improve coronary
- artery perfusion and improve cardiac output.
- Prepare the client for immediate reperfusion procedures such as PTCA or coronary artery bypass graft.
- Monitor arterial blood gas levels and prepare to treat imbalances.
- Monitor urinary output.
- Assist with the insertion of a pulmonary artery (Swan-Ganz) catheter to assess degree of heart failure; readings obtained from the catheter correlating to cardiogenic shock include an increased pulmonary capillary wedge pressure (PCWP) and a decreased cardiac output
- Monitor distal pulses and maintain the transducer at the level of the right atrium if the client has a Swan-Ganz catheter.
Central venous pressure (CVP)
- The CVP is the pressure within the superior vena cava; it reflects the pressure under which blood is returned to the superior vena cava and right atrium.
- The CVP is measured with a central venous line in the superior vena cava.
- Normal CVP pressure is about 3 to 8mmHg.
- An elevated CVP indicates an increase in blood volume as a result of sodium and water retention, excessive IV fluids, alterations in fluid balance, or renal failure.
- A decreased CVP indicates a decrease in circulating blood volume and may be a result of fluid imbalances, hemorrhage, or severe vasodilation, with pooling of blood in the extremities that limits venous return.
- The right atrium is located at the midaxillary line at the fourth intercostal space; the zero point on the transducer needs to be at the level of the right atrium.
- The client needs to be supine, with the head of the bed at 45 degrees.
- The client needs to be relaxed; note that activity that increases intrathoracic pressure,