Shock and Sepsis NCLEX questions

Sepsis NCLEX ScienceMedicineNursing aisog Save Shock and Sepsis NCLEX questions 28 terms T_Adams7Preview Shock NCLEX Questions, Nclex Que...201 terms felicia_ramnandan P Preview Nclex Questions for Shock - Critical ...32 terms karmageniePreview Sepsis 17 terms tka 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)

ANS: 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

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

rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low.Which of these orders by the health care provider will the nurse question?

• Give furosemide (Lasix) 40 mg IV.
• Increase normal saline infusion to 150 mL/hr.
• Administer hydrocortisone (SoluCortef) 100 mg IV.
• Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.

ANS: A

Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.

• A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP

92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question?

• Infuse normal saline at 250 mL/hr.
• Keep head of bed elevated to 30 degrees.
• Give nitroprusside (Nipride) unless systolic BP <90 mm Hg.
• Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

ANS: A

The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.

• After receiving 1000 mL of normal saline, the central venous pressure for a patient who

has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of

• nitroglycerine (Tridil).
• drotrecogin alpha (Xigris).
• norepinephrine (Levophed).
• sodium nitroprusside (Nipride).

ANS: C

When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR.

• The emergency department (ED) receives notification that a patient who has just been in

an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain

• 500 mL of 5% albumin.
• lactated Ringer's solution.
• two 14-gauge IV catheters.
• dopamine (Intropin) infusion.

ANS: C

A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities.Although colloids may sometimes be used for volume expansion, crystalloids should be used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the initial therapy for hypovolemic shock.

• Which of these findings is the best indicator that the fluid resuscitation for a patient with

hypovolemic shock has been successful?

• Hemoglobin is within normal limits.
• Urine output is 60 mL over the last hour.
• Pulmonary artery wedge pressure (PAWP) is normal.
• Mean arterial pressure (MAP) is 65 mm Hg.

ANS: B

Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

• Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient

information indicates that the nurse should consult with the health care provider before administration of the norepinephrine?

• The patient's central venous pressure is 3 mm Hg.
• The patient is receiving low dose dopamine (Intropin).
• The patient is in sinus tachycardia at 100 to 110 beats/min.
• The patient has had no urine output since being admitted.

ANS: A

Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

• A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32,

temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first?

• Give normal saline IV at 500 mL/hr.
• Infuse drotrecogin- (Xigris) 24 mcg/kg.
• Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
• Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to

70 mm Hg.

ANS: A

Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

• When caring for a patient who has septic shock, which assessment finding is most

important for the nurse to report to the health care provider?

• BP 92/56 mm Hg
• Skin cool and clammy
• Apical pulse 118 beats/min
• Arterial oxygen saturation 91%

ANS: B

Since patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information also will be reported, but does not indicate deterioration of the patient's status.

• A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
• administer oxygen.
• attach a cardiac monitor.
• obtain the blood pressure.
• check the level of consciousness.

ANS: A

The initial actions of the nurse are focused on the ABCs—airway, breathing, circulation—and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.

• During change-of-shift report, the nurse learns that a patient has been admitted with

dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider?

• Decreased bowel sounds
• Apical pulse 110 beats/min
• Pale, cool, and dry extremities
• New onset of confusion and agitation

ANS: D

The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.