Shock and Sepsis NCLEX questions

Shock and Sepsis NCLEX questions ScienceMedicineNursing T_Adams7 Save Shock NCLEX Questions, Nclex Que...201 terms felicia_ramnandan P Preview Nclex Questions for Shock - Critical ...32 terms karmageniePreview Sepsis NCLEX 48 terms aisogPreview Shock, 187 term ann The nurse is caring for postoperative clients at risk for hypovolemic shock. Which of the following would cause the nurse to suspect that the client has early shock?

• Hypotension
• Bradypnea
• Irregular heart rhythm
• Tachycardia
• Hypotension

When caring for an obtunded ED client with shock of unknown origin, which action should the nurse take first?

• Establish IV access and hang prescribed infusion
• Apply the automatic BP cuff
• Assess level of consciousness and pupil response to light
• Check the airway and respiratory status
• Check the airway and respiratory status

When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

The nursing assistant reports concerns about the postoperative client who has BP 90/60, HR 80, R 22. What should the RN do?

• Compare these VS with last several readings
• Request that the surgeon come see the client
• Increase the rate of IV fluids
• Reassess VS using different equipment
• Compare these vital signs with the last several readings.

Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment should be used when vital signs are taken postoperatively.A postoperative client is admitted to the ICU with hypovolemic shock. Which nursing action should the nurse delegate to the experienced nursing assistant?

• Obtain vital signs every 15 minutes
• Measure hourly urine output
• Check oxygen saturation
• Assess level of alertness
• Measure hourly urine output

Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.When caring for client with hypovolemic shock with these assessment findings, T 97.9, P 122, R 24, BP 86/48, total urine output 20mL in last 2 hours, skin cool and clammy, which of the following orders would the nurse question?

• Dopamine (Intropin) 12mcg/kg/min
• Dobutamine (Dobutrex) 5mcg/kg/min
• Plasmanate 1 unit
• Bumetanide (Bumex) 1mg IV
• Bumetanide (Bumex) 1mg IV

A diuretic such as bumetanide will decrease blood volume in a client who is already hypovolemic; this order should be questioned because this is not an appropriate action to expand the client's blood volume. The other orders are appropriate for improving blood pressure in shock, and do not need to be questioned.Which change in the client with hypovolemic shock indicates to the nurse that treatment is effective?

• Urine output increases from 5mL/hr to 25mL/hr
• Pulse pressure decreases from 35mmHg to 28mmHg
• Respiratory rate increases from 22/minute to 26/minute
• Body temperature increases from 98.2F to 98.8F
• Urine output increases from 5mL/hr to 25mL/hr

We want the urine output to increase

Which of the following would indicate a positive outcome after starting dopamine (Intropin)?

• Hourly urine output of 10-18 mL
• BP 90/60 and MAP 70
• Blood glucose 245
• Serum creatinine 3.6mg/dL
• BP 90/60 and MAP 70

Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response in this case. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and are a negative consequence of shock, not a positive response. Although a blood glucose of 245 mg/dL is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.How does the nurse recognize that the client is in early stages of septic shock?

• Pallor and cool skin
• Blood pressure 84/50
• Tachypnea & tachycardia
• Respiratory acidosis
• Tachypnea & tachycardia

The nurse is caring for a group of clients at risk for sepsis. Which of the following puts the client at highest risk?

• Pernicious anemia
• Pericarditis
• Post-kidney transplant
• Client owns an iguana
• Post-kidney transplant

Which problem places the client at highest risk for septic shock?

• Stage III Chronic Kidney Disease
• Cirrhosis
• Lung cancer
• 40% burn injury
• 40% burn injury

The nurse is providing discharge teaching to the post-operative client. Which statement by the client indicates need for more teaching?

• "I must call the doctor if I develop a fever."
• "I will call my provider if I have any pain."
• "If the dressing gets soaked with bright red blood I will call the doctor."
• "If the incision is red and swollen, I will call the provider."
• "I will call my provider if I have any pain."

Which of the following indicate early sepsis, which has an excellent recovery rate if treated promptly?

• Localized erythema and edema
• Low-grade fever & low white blood cell count
• Low oxygen saturation & decreased cognition
• Reduced urinary output & increased respiratory rate
• Reduced urinary output & increased respiratory rate

How does the nurse recognize that the client with septic shock has severe tissue hypoxia?

• PaCO2 58mm Hg
• Lactate level 9.0mmol/L

C. INR 1.6

• Potassium 2.8mEq/mL
• Lactate level 9.0mmol/L

The nurse plans to administer an antibiotic to the client newly admitted with septic shock. Which of the following is the most appropriate action for the nurse to take first?

• Administer the antibiotic immediately
• Ensure that blood cultures were drawn
• Obtain signature for informed consent
• Take the client's vital signs
• Ensure that blood cultures were drawn

Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours; timing is essential.Which manifestations of shock are a result of compensatory mechanisms to maintain circulating blood volume?

• Edema and weight gain
• Confusion and lethargy
• Decreased urine output and thirst
• Increased pulse and respiratory rates
• Decreased urine output and thirst

Rationale: Both reduced urine output and thirst are stimulated by a decreasing circulating blood volume. When people can respond to thirst by drinking, the action compensates temporarily by increasing circulating fluid volume. Decreased or absent urine output compensates by preventing a greater fluid loss. The fluid that would have been lost from the body as urine is retained. This is why hourly urine output measurements are such a sensitive indicator for whether shock is improving or progressing. Edema and weight gain are not compensations for circulating blood volume. Confusion and lethargy are responses to circulating blood volume, not compensation to improve it. Increasing pulse and respiratory rates compensate for hypoxia, not for reduced volume.