Adult Health 2 Exam 2 with Verified Answers
1. shock: widespread abnormal cellular metabolism. occurs when gas exchange
with oxygenation and tissue perfusion needs are not sufficiently met to maintain cell
function.
2. what are the types of shock?: hypovolemic, cardiogenic, distributive, and ob...
Adult Health 2 Exam 2 with Verified Answers
1. shock: widespread abnormal cellular metabolism. occurs when gas exchange
with oxygenation and tissue perfusion needs are not sufficiently met to maintain cell
function.
2. what are the types of shock?: hypovolemic, cardiogenic, distributive, and ob-
structive
3. sepsis: infection that causes tissue damage, organ failure, and death if not
treated promptly
4. septic shock: a subset of sepsis in which circulatory, cellular, and metabolic
abnormalities substantially increase the risk of death over that associated with
sepsis alone
5. SIRS (systemic inflammatory response syndrome): widespread inflammation
that can occur in infection, trauma, shock. May result from or lead to MODS.
6. MODS (multiple organ dysfunction syndrome): Complication of any form of
shock. organs failing. Need at least two systems affected.
7. infection to septic shock: -local infection
-systemic infection (early sepsis)
-SIRS
-organ failure (severe sepsis)
-MODS- septic shock
-death
8. sepsis and septic shock prevention: -evaluate risk
-use aseptic technique
-removing catheters and IVS as soon as they are no longer needed
-wean from vent ASAP.
-early detection
-MEWS
9. risk factors for sepsis: -immunocompromised patients
-patients with central lines.
10. early signs and symptoms of sepsis: -mild hypotension, decreased output
-mildly increased RR
-warm or cool and clammy skin
-low grade fever, high fever, or low temp
-low urine output
-restless, fidgety
11. advanced sepsis signs and symptoms: -rapid HR, elevated systolic BP, in-
creased output
-increased RR, low O2 sat
-warm, little to no cyanosis
-low grade fever, high fever, or low temp
, Adult Health 2 Exam 2 with Verified Answers
-little to no urine output
-change in LOC and affect, may voice feelings of impending doom
12. what is a possible risk of advanced sepsis/septic shock?: disseminated
intravascular coagulation
13. what causes hyperglycemia in an advanced septic patient?: hyperglycemia
is caused by a stress response from the liver, causing excess glucose to be released.
14. 1 hour bundle for management of sepsis: -measure lactate level
-obtain blood cultures before administration of antibiotics
-administer broad spectrum antibiotics
-begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate > or =
4mmol/L
-apply vasopressors if hypotensive during or after fluid resuscitation to maintain a
mean arterial pressure > or = 65 mmHG
15. A 39-year-old client is admitted with a severely abscessed tooth. The
nurse assess vital signs of BP 92/44, HR 134, RR 26, Spo2 90% on room air,
temperature 38.9º C. What is the priority nursing intervention?
A.Administer prescribed antibiotics.
B.Obtain blood cultures and other labs.
C.Insert an indwelling urinary catheter.
D.Initiate intravenous fluid resuscitation.: D.
16. When assessing a client who has been admitted to for suspected sepsis,
which finding does the nurse identify as the earliest sign?
A. Anuria
B. Increased heart rate
C.Decreased respiratory rate
D.Change in systolic and diastolic blood pressure: B
17. Which assessment finding in a client in the refractory phase of shock
requires immediate nursing intervention?
A. Warm, flushed skin
B. Urine output of 20 mL/hr
C.Increasing respiratory rate
D.Bleeding, oozing from IV sites: D.
18. hazards and complications of oxygen therapy: -combustion
-oxygen toxicity
-absorptive atelectasis
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