Shock and Sepsis NCLEX Questions and

Shock and Sepsis NCLEX Questions and Correct Solutions Graded to Pass 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 - ✔✔ A. 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 - ✔✔ D. 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 - ✔✔ A. 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. 1 / 2

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 - ✔✔ B. 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 - ✔✔ D. 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 - ✔✔ A. Urine output

increases from 5mL/hr to 25mL/hr We want the urine output to increase

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