NUR 325 Exam 4 New Latest Version Updated 2024-2025
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Which patient is most at risk for developing septic shock?
A - 45 year old patient 12 days post op from a lumbar fusion with a heart rate of 95 and a temp of 100.1F
B - 27 year old patient with a UTI and WBC 13,000
C - 87 year old patient admitted for frequent falls with a blood pressure of 105/68
D - 58 year old patient with cellulitis and a lactic acid of 3.9 ---------- Correct Answer ---------- D active
infection and lactic acid >2
Your patient has been diagnosed with sepsis. Which orders would you expect to see? SATA
A - Draw blood cultures
B - 0.9% NaCl infusion at 125ml/hr continuous
C - CBC and CMP
D - Piperacillin-Tazobactam IV 25ml/hr Q 8 hours
E - Protonix 40mg IV daily ---------- Correct Answer ---------- all of the above
Your patient has sepsis with the following vital signs: BP 75/34, HR 120, RR 22, temp 98.9F, O2 95%.
Which order would the nurse implement first?
A - Docusate Sodium 100mg
B - Norepinephrine 0.5mcg IV continuous, titrate to effect
C - 12 lead EKG
D - 1000ml 0.9% NaCl IV bolus ---------- Correct Answer ---------- D - fluids first then vasopressors
What position is seen in the passive leg raise?
A - Trendelenberg
B - Lithotomy
C - Prone
D - Semi-recumbent ---------- Correct Answer ---------- D
Which patient is at risk for multi-organ dysfunction syndrome (MODS)?
A - Patient with diminished lung sounds and BP 105/60
B - Patient on hemodialysis and takes epoetin
C - Patient with jaundice and venous jugular distention
D - Patient with lymphedema and cellulitis ---------- Correct Answer ---------- C
Your patient has the following labs and vital signs: hemoglobin 6.0g/dL, platelets 50,000, BP 84/57, HR
115, RR 17, SpO2 94% on 6L O2. The nurse receives the following orders. Which should the nurse
implement first?
A - Heparin IV infusion started at 10unit/kg/hr continuous
B - Norepinephrine 0.5mg IV once
C - 2 units PRBCs
D - Nimodipine 60mg oral BID ---------- Correct Answer ---------- C - increase hemoglobin, increase
blood pressure, hopefully wean off oxygen
Your patient had a severe burn and has urine that is positive for a significant amount of myoglobin.
Which complication is this a sign of?
A - Rhabdomyolysis
,B - Carbon monoxide poisoning
C - Hypoxia
D - Cardiogenic shock ---------- Correct Answer ---------- A
There was a fire at a nearby apartment complex. Four people were injured and brought into the ED.
Which one should you see first?
A - Patient with a third degree18% TSBA burn of the right leg with tingling
B - Patient with a circumferential second degree burn to the abdomen asking for pain medication
C - Patient with an epidermis layer burn to the entire back that's peeling
D - Patient with second degree burns to the face and neck and requiring 5L of O2 ---------- Correct
Answer ---------- D
Alteration in which of the following does not contribute to shock?
A - Blood volume
B - Myocardial contractility
C - Capillary refill
D - Vascular resistance ---------- Correct Answer ---------- C
rationale: alterations in all other options contribute to shock
SIRS can be caused by... (SATA)
A - Trauma
B - Infection
C - Singultus
D - Ischemia
E - 0.8 Lactic acid ---------- Correct Answer ---------- A, B, D
C - hiccups
E - normal lactic acid level
Anaerobic metabolism is seen in which phase of shock?
A - Refractory
B - Progressive
C - Initiation
D - Compensatory ---------- Correct Answer ---------- B
Which of the following are symptoms seen in the compensatory phase?
A - ARDS, DIC, AKI
B - Anuria, acidosis, hyperglycemia
C - No apparent symptoms
D - Oliguria, restlessness, hypotension responsive to fluids ---------- Correct Answer ---------- D
A - refractory
B - progressive
C - initiation
A patient with the following vital signs: HR 118, RR 18, temp 99.3F, O2 92%, BP 74/43. The patient has
received 2L of 0.9% NaCl fluid boluses. Which of the following orders should the nurse implement first?
A - Tylenol 625mg rectal suppository
B - Fentanyl IV 0.5-1.0 mcg/hr continuous infusion, titrate to effect
C - 1000ml Lactated Ringer's bolus
,D - Norepinephrine 0.5-1.0 mcg/hr continuous infusion, titrate to effect ---------- Correct Answer ----------
D
Rationale: Blood pressure not responding to fluids alone. Need to begin pressors.
A patient is diagnosed with septic shock. As the nurse you know this is a _______ form of shock. In
addition, you're aware that _____ and ______ are also this form of shock.
A - Obstructive; hypovolemic and anaphylactic
B - Distributive; anaphylactic and neurogenic
C - Obstructive; cardiogenic and neurogenic
D - Distributive; hypovolemic and obstructive ---------- Correct Answer ---------- B
Your patient has 73% TBSA burns and weighs 128kg. Using the Parkland Formula, how much Lactated
Ringer's would they get in the first 8 hours? (2 mL/kg/%TBSA)
A - 4672ml
B - 9344ml
C - 18688ml
D - 6229ml ---------- Correct Answer ---------- B
What is shock? ----------- Correct Answer ------------ -Life-threatening response to alterations in
circulation
-***Inadequate tissue perfusion***
-Imbalance between cellular oxygen supply and demand
-Can lead to organ failure and death
-Hypoperfusion of tissues, hypermetabolism, & activation of inflammatory response
What is the first system to be affected by shock and what are the early and late signs and symptoms? ------
----- Correct Answer ------------ -CNS affected first by changes in cell perfusion
-Early: restless, agitated, and anxious
-Later: confused & lethargic
What would we want our MAP to be at? What is the normal range? ----------- Correct Answer ------------ -
65 or higher
-Normal is 60 to 100
How does our respiratory system respond to shock? ----------- Correct Answer ------------ -Early: rapid and
deep resps (like metabolic acidosis)
-Poor gas exchange
-May need to intubate
-ABGs
What would a patients urine output be if they have oliguria? ----------- Correct Answer ------------ Less
than 0.5 ml/kg/h
Why would a patient have oliguria from sepsis? ----------- Correct Answer ------------ Urine output
decreases because the body retains sodium and keeps water in the kidneys
How does shock affect the liver? ----------- Correct Answer ------------ -Prolonged clotting
-Petechiae
-Ecchymosis may occur
, ***What are the normal lactate levels?*** ----------- Correct Answer ------------ ***Less than 2***
***Why is it important to assess serum lactate levels for patients with suspected shock?*** -----------
Correct Answer ------------ ***Indicate decreased oxygen delivery to the cells***
What are the stages of shock? ----------- Correct Answer ------------ Initial
Compensatory
Progressive
Refractory
What is the initiation phase of shock? ----------- Correct Answer ------------ -Inadequate delivery of
oxygen leads to hypoperfusion
-No obvious clinical signs noted but might see decreased CO
-Reversible
What is the compensatory phase of shock? ----------- Correct Answer ------------ -Sustained reduction in
tissue perfusion initiates responses to maintain blood flow to organs
-Initiation of compensatory mechanisms
-Reversible
What are the manifestations of the compensatory stage of shock? ----------- Correct Answer ------------ -
Increased HR
-Narrowed pulse pressure
-Thirst
-Cool, moist skin
-Oliguria
-Diminished bowel sounds
-Restlessness progressing to confusion
-Hyperglycemia
-Increase urine specific gravity
-Rapid deep resps causing respiratory alkalosis
What is normal urine specific gravity? ----------- Correct Answer ------------ 1.005-1.030
How would you treat a patient in the compensatory stage of shock? ----------- Correct Answer ------------ -
Treat underlying cause
-Fluids & O2
-Maintain BP and tissue perfusion
-Frequent assessment (subtle changes in LOC, I&O, respiratory and heart rate, BP or MAP)
What is the progressive phase of shock? ----------- Correct Answer ------------ -Sustained hypo-perfusion
and vasoconstriction results in significant peripheral tissue ischemia
-Failure of compensatory mechanisms
-Treatment will require more than just fluid resuscitation
What are the manifestations of a patient in the progressive stage of shock? ----------- Correct Answer ------
------ -BP no longer compensated
-MAP below normal limits (60-100)
-Decreased mental status
-Rapid and shallow resps
