Med-Surg Ch. 37

A registered nurse is teaching a student nurse about the etiology of severe sepsis. Which statements about sepsis made by the student indicate effective learning? Select all that apply.

"Sepsis is commonly seen in AlIDS patients." "In an immunocompromised patient, bacteria and fungi can cause sepsis." "Central venous access devices increase the risk of sepsis.

Which patient should be further evaluated for septic shock?

A patient with a temperature of 100 °Fand total bilirubin 7 mg/dL

Which patient is at the highest risk for developing septic shock?

A 65-year-old with prostate cancer receiving chemotherapy

What typical sign/symptom indicates the early stage of septic shock?

Tachypnea and tachycardia

Which clinical manifestation is associated with septic shock?

Cool skin

The nurse is caring for a patient with septic shock. Which blood glucose levels indicate a positive outcome?

140 mg/dL

Which problem places a patient at highest risk for septic shock?

40% burn injury

Which patient does the nurse consider to be at highest risk for the development of sepsis?

45-year-old woman 2 days postoperative from bowel for surgery treatment of cancer

Which patients may be at high risk for sepsis? Select all that apply.

A 50-year-old malnourished man An 82-year-old man with diabetes A 30-year-old woman with massive burns

Which assessment data suggest that a patient who suffered a spider bite 12 hours prior has sepsis? Select all that apply.

Increased respiratory rate Decreased blood pressure Increased serum glucose level

A patient admitted with pneumonia and possible sepsis has a blood pressure of 90/46 mm Hg, heart rate of 128 beats/min, respiratory rate of 28/min, temperature of 101.3° F (38.5° C), no urine output for 4 hours, and central venous pressure of 2 mm Hg. The patient arouses to name but is not oriented. Which order does the nurse implement first?

Administer 500 mL intravenous colloid bolus over 30 minutes.

The laboratory report of a patient with sepsis shows a serum lactate level of 40 mg/dL. Which intervention would be most appropriate in this patient?

Administering crystalloids intravenously

An older adult underwent cholecystectomy. Following the surgery, the patient developed breathing difficulty, and had a heart rate more than 95 beats a minute, breathing rate 20 beats a minute, a temperature of 102.4 F, and an elevated blood glucose level. Which assessment will help in confirming this patient's condition?

Blood culture

A patient with septic shock has been started on dopamine at 12 mcg/kg/min. Which indicates a positive response outcome?

Blood pressure 90/60 and mean arterial pressure (MAP) 70

How does the nurse caring for a patient with septic shock recognize that severe tissue hypoxia is present?

Lactate level 9.0 mmol/L

Which finding contributes to an acidotic state in a patient with septic shock?

Lactate level of 9.2 mmol/L

Which clinical symptoms in a postoperative patient indicate early sepsis with an excellent recovery rate if treated?

Low-grade fever and mild hypotension

A patient with sepsis and septic shock underwent a thorough treatment with appropriate interventions. Which are the expected outcomes of this treatment? Select all that apply.

Normal aerobic cellular metabolism Arterial blood gases within normal range Absence of multiple organ dysfunction syndrome

A 65-year-old patient is being treated at a hospital. Which intervention helps prevent the risk of sepsis and septic shock in the patient?

Using aseptic technique

A patient is receiving antineoplastic chemotherapy. Which measure does the nurse teach that will help prevent infection and sepsis?

Wash the dishes in the dishwasher.

The nurse is instructing a patient about infection prevention strategies to reduce the risk of sepsis. Which patient response suggests further self-management teaching is needed prior to discharge?

'I won't need help anymore to care for my cats and change the litter box.

Which clinical manifestations distinguish septic shock from hypovolemic shock? Select all that apply.

Decreased blood pressure Increased blood glucose level

Which is a risk factor for distributive shock?

Diminished immune response

Which laboratory result is seen in late sepsis?

Decreased segmented neutrophil count

A patient was given treatment for sepsis and discharged from the hospital. After a few days, the patient again presented with severe sepsis. What is the best anticipated reason for this?

Due to a delay in the disease progression

Which physiological change is related to septic shock?

Elevated WBC count

The nurse plans to administer an antibiotic to a patient newly admitted with septic shock. What action does the nurse take first?

Ensure that blood cultures were drawn.

A laboratory investigation of a patient with sepsis and septic shock reveals adrenal insufficiency in the patient. Which drugs should the primary health care provider prescribe?

Hydrocorisone

Which drug is prescribed particularly in patients with septic shock?

Hydrocortisone

Which medications are often used to provide adrenal support for the patient with severe sepsis? Select all that apply.

Hydrocortisone Fludrocortisone

Which physiological change in a patient with septic shock indicates a poor prognosis?

Hypodynamic cardiac function

The nurse is teaching a patient who is at risk of sepsis about self-management. Which statement made by the patient indicates the need for further teaching?

I will go for a hemoglobin check weekly.

A patient is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate?

Broad-spectrum antibiotics

What is the cause being reduced urine output in patients suffering from sepsis during systemic inflammatory response syndrome?

Impaired oxygenation and perfusion

A patient's report shows an elevated level of plasma C-reactive protein, glucose, creatinine, and adrenal insufficiency. The patient has an increased heart rate and breathing rate. Which other finding does the nurse observe mostly in the patient?

Increased fluid intake and decreased output

Which medications should be specifically included in the care plan of a patient with septic shock? Select all that apply.

Insulin therapy Low-dose corticosteroids Broad spectrum IV antibiotics

Which finding may reflect increased cardiac output in patients with septic shock?

Normal central venous pressure

A patient is admitted with new-onset hypotension, tachycardia, tachypnea, and elevated white blood cell count, but blood cultures are negative. The patient is becoming increasingly confused. What is the nurse's best action?

Notify the Rapid Response Team.

While caring for a patient with sepsis, the nurse finds that the patient is showing signs of systemic inflammatory response syndrome. What is the immediate nursing intervention in this situation?

Notify the rapid response team.

The nurse is caring for a patient newly admitted for suspected septic shock. Which intervention should the nurse implement first?

Obtain blood cultures.

A patient with which problem or condition is at highest risk for septic shock?

On prednisone therapy for rheumatoid arthritis

The nurse is assessing the laboratory reports of blood glucose levels in four different patients. Which patient's blood glucose level would be indicative of sepsis and septic shock?

Patient B

After assessing a patient, the nurse suspects that the patient is suffering from severe sepsis. Which clinical findings present in the patient helped the nurse reach this conclusion?

Plasma glucose - 140 mg/dl

Which blood product is mostly preferred in patients with septic shock?

Platelets

Which problem places a patient at highest risk for sepsis?

Post-kidney transplant

Which parameter reduction indicates the beginning of severe sepsis?

Protein C

Which conditions are identified as specific causes of distributive shock? Select all that apply.

Sepsis Anaphylaxis Capillary leak

The nurse finds that a patient has been refusing treatment for infection for the past month. Which type of shock does the nurse anticipate in this patient?

Septic shock

The primary health care provider prescribed a plasma C-reactive protein test for a patient. Which shock does the nurse anticipate in this patient?

Septic shock

Which type of shock has no loss of blood volume from the body but has toxic metabolites, which results in organ dysfunction?

Septic shock

Which assessment data suggest that antibiotic therapy may be effective in the treatment of a patient with sepsis?

Serum lactate level increases 3.3 to 4.2 mmol/L

After assessing a patient, the primary health care provider prescribes treatment for septic shock. Which clinical finding does the nurse anticipate before treatment begins in the patient?

Severe hypovolemic shock

Which gram-positive bacteria may cause sepsis and septic shock?

Staphylococcus aureus

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

Temperature

An older patient with a history of diabetes mellitus has a blood pressure of 90/60 mmHg. Further laboratory investigations reveal a white blood cell count (WBC) of 14,000/mm 3 and a urine output of 0.2 mL/kg/hr. What does the nurse infer from these diagnostic findings?

The patient has cardiogenic shock.

A type Il diabetic patient with high fever and cough has decreased mean arterial pressure and an increased level of lactic acid. Based on the reports, the patient is administered fludrocortisone. What does the nurse infer from the findings?

The patient is suffering from septic shock.

A patient has a urine output of 13 mL/hr. What does this value indicate?

The patient's urine output is decreased.

Which physiological changes are seen in a patient with prolonged sepsis? Select all that apply.

Нyроxia Decrease in urine output Change in patient cognition