Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Practice Questions and answers
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Course
Shock, Sepsis & Multiple Organ Dysfunction NCLEX
Institution
Shock, Sepsis & Multiple Organ Dysfunction NCLEX
1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action?
a. Assess the blood pressure by Doppler.
b. Estimate the systolic pressure as 60 mm Hg.
c. Obtain an e...
Chapter 11: Shock, Sepsis, and
Multiple Organ Dysfunction
Syndrome Practice Questions and
answers
1. The nurse is caring for a patient admitted with hypovolemic
shock. The nurse palpates thready brachial pulses but is unable to
auscultate a blood pressure. What is the best nursing action?
a. Assess the blood pressure by Doppler.
b. Estimate the systolic pressure as 60 mm Hg.
c. Obtain an electronic blood pressure monitor.
d. Record the blood pressure as "not assessable." - answer a. Assess
the blood pressure by Doppler.
Auscultated blood pressures in shock may be significantly
inaccurate due to vasoconstriction. If blood pressure is not audible,
the approximate value can be assessed by palpation or ultrasound.
If brachial pulses are palpable, the approximate measure of systolic
blood pressure is 80 mm Hg. This action has the potential to delay
further assessment of a compromised patient in shock.
Documenting a blood pressure as not assessable is not appropriate
without further attempts using different modalities.
2. The nurse has just completed an infusion of a 1000 mL bolus of
0.9% normal saline in a patient with severe sepsis. One hour later,
which laboratory result requires immediate nursing action?
a. Creatinine 1.0 mg/dL
b. Lactate 6 mmol/L
c. Potassium 3.8 mEq/L
,d. Sodium 140 mEq/L - answer b. Lactate 6 mmol/L
Lactate level has been used as an indicator of decreased oxygen
delivery to the cells, adequacy of resuscitation in shock, and as an
outcome predictor. All other listed values are within normal limits
and do not require additional follow-up.
3. The nurse has been administering 0.9% normal saline intravenous
fluids as part of early goal-directed therapy protocols in a patient
with severe sepsis. To evaluate the effectiveness of fluid therapy,
which physiological parameters would be most important for the
nurse to assess?
a. Breath sounds and capillary refill
b. Blood pressure and oral temperature
c. Oral temperature and capillary refill
d. Right atrial pressure and urine output - answer d. Right atrial
pressure and urine output
4. A patient is admitted to the critical care unit following coronary
artery bypass surgery. Two hours postoperatively, the nurse
assesses the following information: pulse is 120 beats/min; blood
pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2
mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest
drainage is 200 mL/hr. What is the best interpretation by the nurse?
a. The assessed values are within normal limits.
b. The patient is at risk for developing cardiogenic shock.
c. The patient is at risk for developing fluid volume overload.
d. The patient is at risk for developing hypovolemic shock. - answer
d. The patient is at risk for developing hypovolemic shock.
, Vital signs and hemodynamic values assessed collectively include
classic signs and symptoms of hypovolemia. Both urine output and
chest drainage values are high, contributing to the hypovolemia.
Assessed values are not within normal limits.
A cardiac output of 4 L/min is not indicative of cardiogenic shock.
The patient is at risk for hypovolemia, not volume overload, as
evidenced by excessive hourly chest drainage and urine output.
5. A patient is admitted after collapsing at the end of a summer
marathon. She is lethargic, with a heart rate of 110 beats/min,
respiratory rate of 30 breaths/min, and a blood pressure of 78/46
mm Hg. The nurse anticipates administering which therapeutic
intervention?
a. Human albumin infusion
b. Hypotonic saline solution
c. Lactated Ringer's bolus
d. Packed red blood cells - answer c. Lactated Ringer's bolus
The patient is experiencing symptoms of hypovolemic shock.
Isotonic crystalloids, such as normal saline and lactated Ringer's
solutions, are the priority intervention. Albumin and plasma protein
fraction (Plasmanate) are naturally occurring colloid solutions that
are infused when the volume loss is caused by a loss of plasma
rather than blood, such as in burns, peritonitis, and bowel
obstruction. Hypotonic solutions rapidly leave the intravascular
space, causing interstitial and intracellular edema and are not used
for fluid resuscitation. There is no evidence to support a transfusion
in the given scenario.
6. The nurse is caring for a patient in the early stages of septic
shock. The patient is slightly confused and flushed, with bounding
peripheral pulses. Which hemodynamic values is the nurse most
likely to assess?
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