Shock and Sepsis NCLEX questions with 100 Verified

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Shock and Sepsis NCLEX questions with 100% Verified Answers Graded A+

• The nurse is caring

for postoperative clients at risk for hypovolemic shock. Which of the fol- lowing would cause the nurse to suspect that the client has early shock?

• Hypotension
• Bradypnea
• Irregular heart rhythm
• Tachycardia
• When caring for an ob-

tunded 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 con-

sciousness and pupil re- sponse to light

• Check the airway and

respiratory status

• The nursing assistant re-

ports concerns about the postoperative client who

• Hypotension

• 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, apply- ing the blood pressure cuff, and assessing for changes in the client's mental status.

• Compare these vital signs with the last several

readings.has BP 90/60, HR 80, R 22. Vital sign trends must be taken into considera- What should the RN do?

• Compare these VS with

last several readings

• Request that the sur-

geon come see the client tion; 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 indicat- ed. The same equipment should be used when vital signs are taken postoperatively. 1 / 2

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Shock and Sepsis NCLEX questions with 100% Verified Answers Graded A+

• Increase the rate of IV

fluids

• Reassess VS using dif-

ferent equipment

• A postoperative client

is admitted to the ICU with hypovolemic shock.Which nursing action should the nurse delegate to the experienced nurs- ing assistant?

• Obtain vital signs every

15 minutes

• Measure hourly urine

output

• Check oxygen satura-

tion

• Assess level of alert-

ness

• 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 clam- my, which of the following orders would the nurse question?

• Dopamine (Intropin)

12mcg/kg/min

• Dobutamine (Dobutrex)

5mcg/kg/min

• Plasmanate 1 unit

• 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 crit- ically ill clients requires the clinical judgment of the critical care nurse because immediate inter- vention may be needed.

• Bumetanide (Bumex) 1mg IV

A diuretic such as bumetanide will decrease blood volume in a client who is already hypov- olemic; this order should be questioned because this is not an appropriate action to expand the client's blood volume. The other orders are ap- propriate for improving blood pressure in shock, and do not need to be questioned.

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