Shock, Mods, SIRS, Sepsis NCLEX questions

Shock, Mods, SIRS, Sepsis NCLEX questions ScienceMedicineNursing kaelynsmith123 Save Shock NCLEX Questions, Nclex Que...201 terms felicia_ramnandan P Preview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview Shock and Sepsis NCLEX questions 28 terms T_Adams7Preview Acute K 18 terms yi_y 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.

Which of the following findings indicate to the nurse that treatment with plasma protein fraction (Plasmanate) is having intended effect?

• Urine output 10-15mL/hr for last 4 hours
• Mean arterial pressure 70
• Albumin level 3.5
• Hemoglobin 7.6
• Mean arterial pressure 70

Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, which is a desired outcome in shock. Urine output should be 0.5 mL/kg/hr, or greater than 30 mL/hr. Albumin levels reflect nutritional status, which may be poor in shock states due to an increased need for calories. Plasmanate expands blood volume by exerting increasing colloid osmotic pressure in the bloodstream, pulling fluid into the vascular space; this does not improve an abnormal hemoglobin.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

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

Not sure if this is correct! Book says different than lecture 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 client is admitted with two of the SIRS variables: temperature 95F & ↑WBC. Which intervention from the Surviving Sepsis bundle should the nurse initiate?

• Broad-spectrum antibiotics
• Blood transfusion
• Cooling baths
• NPO status
• Broad-spectrum antibiotics

Broad-spectrum antibiotics must be initiated within 1 hour of establishing diagnosis. A blood transfusion is indicated for low red blood cell count or low hemoglobin and hematocrit; transfusion is not part of the sepsis resuscitation bundle. Cooling baths are not indicated because the client is hypothermic, nor is this part of the sepsis resuscitation bundle. NPO status is not indicated for this client, nor is it part of the sepsis resuscitation bundle.

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.A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis?

• Temperature
• Pulse
• Respiration
• Blood pressure
• Temperature

A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.The nurse gets the hand-off report on four clients. Which client should the nurse assess first?

• Client with urine output of 40 mL/hr for the last two hours
• Client with a pulse change of 100 to 88 beats per minute
• Client with oxygen saturation unchanged at 94%
• Client with a blood pressure change of 128/74 to 110/88 mm Hg
• Client with a blood pressure change of 128/74 to 110/88 mm Hg