Sepsis NCLEX Exam With Questions And Answers

Sepsis NCLEX Exam With Questions And Answers

Why are the manifestations of most types of shock the same regardless of what specific events or condition caused the shock to occur?

• The blood, blood vessels, and heart are directly connected to each other so that when

one is affected, all three are affected.

• Because blood loss occurs with all types of shock, the most common first

manifestation is hypotension.

• Every type of shock interferes with oxygenation and metabolism of all cells in the

same sequence.

• The sympathetic nervous system is triggered by any type of shock and initiates the

stress response. - AnswerANS: D

Rationale: Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems.Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective?

• Urine output increase from 5 mL/hr to 25 mL/hr
• Pulse pressure decrease from 35 mm Hg to 28 mm Hg
• Respiratory rate increase from 22 breaths/min to 26 breaths/min
• Core body temperature increase from 98.2 F (36.8 C) to 98.8 F (37.1 C) - AnswerANS: A

Rationale: During shock, the kidneys and baroreceptors sense an ongoing decrease in MAP and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output.ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase.Which newly admitted client does the nurse consider to be at highest risk for

development of sepsis?

• 75-year-old man with hypertension and early Alzheimer's disease
• 68-year-old woman 2 days postoperative from bowel surgery
• 80-year-old community-dwelling man with no other health problems undergoing

cataract surgery

• 54-year-old woman with moderate asthma and severe degenerative joint disease of the

right knee - AnswerANS: B

Rationale: The 68-year-old woman has several risk factors. First she is an older adult, and immune function decreases with age. The greatest risk factor is that she has just had bowel surgery. Not only does major surgery further reduce the immune response, the bowel cannot be "sterilized" for surgery. Therefore the usual bacteria of the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted.A 30-year-old man comes to the emergency department because of increasing pain in the left upper abdominal quadrant. Several hours ago, he was hit hard in that area during a tackle by the head of a football player who was wearing a helmet. He has no other health problems, and the only drug he takes on a regular basis is 325 mg of aspirin daily. These are his vital signs: pulse, 102; respirations, 22; blood pressure, 110/86; oxygen saturation, 96%. He has not eaten since he was hit but did drink a bottle of water on the way to the hospital because he was thirsty. When you examine his abdomen, bruising is present in the left upper quadrant and extends down his left side.

• Where else should you look for evidence of bleeding?
• What manifestations of shock are present?
• How would you classify this stage of shock? Provide a rationale for your evaluation.
• What additional information should you obtain?
• What vital sign(s) should you monitor most closely? - AnswerSuggested Responses:
• Where else should you look for evidence of bleeding?

His left kidney could have been jarred with this injury even though the blow occurred to the abdomen rather than the back (the kidney is located on the posterior abdominal wall).Check any urine for gross or occult blood. If he has been lying down, blood released as a result of internal bleeding could pool in the posterior area as a result of gravity. Therefore check his lower back area.

• What manifestations of shock are present?

The patient has a rapid pulse, narrowed pulse pressure, oxygen saturation below 98% (he is young and, with no other health problems, should have an oxygen saturation of 98% or higher), and he is thirsty.

• How would you classify this stage of shock? Provide a rationale for your evaluation.

He is most likely in the nonprogressive stage of shock. He is thirsty, indicating that hormonal compensatory mechanisms have started. In addition, his oxygen saturation is lower than normal for his age and health. Because his usual blood pressure is unknown, the shock stage cannot be established on that basis.

• What additional information should you obtain?

Ask the patient if he knows his usual blood pressure. If he has been to this hospital system before, this information might be available in his electronic medical record. Ask when he last urinated and how much. If he is able to urinate, measure the amount and check for blood. If he cannot urinate, scan his bladder to determine whether he has produced any urine. Assess nail beds and oral mucous membranes for pallor or cyanosis. Also check capillary refill. Determine whether he can take a deep breath. He was hit in the upper quadrant, and it is possible that a rib could be fractured. He should have blood drawn for a hematocrit (and possibly hemoglobin) level, although this must be requested by the health care provider.

• What vital sign(s) should you monitor most closely?

Closely monitor the patient's heart rate, pulse oximetry, urine output, blood pressure, and level of consciousness.

• 825, Patient-Centered Care; Evidence-Based Practice

The patient is an 82-year-old woman who has been a resident in an extended-care facility for the past year because of poor mobility and self-care problems. Today she is brought to the emergency department because she does not recognize her son and does not know where she is. She completed drug therapy for a urinary tract infection 1 week ago.Her skin is thin, and she has many bruises. In addition, she has a healing wound on her left shin, which her son tells you occurred 3 days ago when she scraped the area trying to get out of bed alone. The skin immediately surrounding the wound appears normal; however, about 3 inches to the right of the wound the skin is red, firm, and warm to the touch. These are her vital signs: T, 100.8 F (38.2 C); P, 112 beats/min; R, 24 breaths/min; BP, 118/80; SpO2, 92%. Oxygen at 3 L/min is applied until the neurologist can evaluate her, and an IV with normal saline is started at 100 mL/hr. Her son is concerned because she was given her oral antidiabetic drug this morning (5 hours ago) but has not eaten breakfast or lunch. When you check her blood glucose level, it is 131 mg/dL. When you assess her 15 minutes later, her oxygen saturation is 90%.

• What risk factors does this patient have for sepsis?
• What manifestations does she have that are consistent with sepsis and systemic

inflammatory response syndrome (SIRS)?

• What assessment should you perform immediately?

• What would be the most likely source of infection?
• Should you express concern about the possibility of sepsis and SIRS to the emergency

department intensivist? Why or why not? - AnswerSuggested Responses:

• What risk factors does this patient have for sepsis?

Risk factors include older age, diabetes mellitus, poor mobility and self-care problems, a known urinary tract infection within the past 30 days, and an open skin area on a lower extremity.

• What manifestations does she have that are consistent with sepsis and systemic

inflammatory response syndrome (SIRS)?Manifestations include elevated temperature, a heart rate of more than 90 beats/min, a respiratory rate greater than 20 breaths/min, a blood glucose level above 120 mg/dL, a recent known infection, decreasing oxygen saturation, and confusion.

• What assessment should you perform immediately?

Assess the color of her skin and mucous membranes, capillary refill, and capnography.Obtain an order for a serum lactate level and a complete blood count with differential.Also obtain an order to insert a Foley catheter for accurate urine output assessment.

• What would be the most likely source of infection?

The two most likely sources of infection are the leg wound (even though the red area is adjacent to the scrape, it is an indication of cellulitis) and the urinary tract.

• Should you express concern about the possibility of sepsis and SIRS to the emergency

department intensivist? Why or why not?Absolutely; this patient meets multiple criteria for sepsis with SIRS and she is older. Her condition could worsen rapidly to severe sepsis and multiple organ dysfunction syndrome (MODS). She needs immediate intervention to save her life.

• A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The

pulse