NCLEX sepsis questions
A patient with septic shock has the following VS: 70/46 mm Hg, RR 32, T 104 and blood gluose of 246 mg/dL. Which of these prescribed interventions will the nurse implement first? A. Give NS IV at 500mL/ hr. B. Infuse drotrecogin- (Xigris) mcg/ kg. C. Start insulin drip to maintain blood glucose at 110-150 mg/ dL. D. Titrate norepinephrine (Levophed) to keep MAP at 65- 70mm Hg.
A
Choose the correct progression of sepsis and septic shock a. local infection -> systemic infection -> SIRS -> organ failure -> MODS -> death b. local infection -> systemic infection -> organ failure -> MODS -> death c. local infection -> systemic infection -> organ failure -> MODS -> SIRS -> death d. systemic infection -> local infection -> SIRS -> organ failure -> MODS -> death
A
The nurse in the ICU is assigned to care for a patient with sepsis. Which of the following is NOT an early sign of septic shock? A. Bradypnea B. Tachycardia C. Fever D. Abnormal WBC count
A
What is an early, reliable sign of impending physiological compromise? A) Tachypnea B) Fever C) Confusion D) Shivering
A
What are signs of Sepsis/Septic shock? a. tachycardia b. hypotension c. fever d. bradycardia e. polyuria f. malaise g. tachypnea
A, B, C, F, G
A patient is diagnosed with sepsis. Which of the following treatments should be completed within the first 3 hours? Select all that apply. A. Obtain blood cultures prior to th administration of antibiotics B. Measure lactate level C. Administer vasopressors D. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L E. Re measure lactate if initial lactate elevated
A, B, D
A patient with a hx of pneumonia reports to the ED and is given a working diagnosis of sepsis. Which of the following symptoms would accompany this diagnosis? Select all that apply. A) Fever B) Bradypnea C) Tachycardia D) Confusion E) Cool, dry skin
A, C, D
What assessment findings would a nurse expect in a patient experiencing septic shock? Select all that apply. A. Tachycardia B. Bradycardia C. Hypertension D. Hypotension E. Bradypnea
A, D
1. What is the priority intervention when treating a septic patient? a. Administer vasopressors b. Begin the patient on TPN c. Administer a broad-spectrum antibiotic d. Begin administration of IV fluid replacement
D
A patient in the ICU has developed sepsis. Which of the following presentations would you not expect to see? A. Tachypnea B. Fever C. Diaphoresis D. Bradycardia
D
A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? A. fungus B. viral C. Parasite D. bacteria
D
All of the following are part of the refractory stage of Sepsis except: a. too little oxygen results in cell death b. the body no longer responds to interventions c. irreversible d. Hyperkalemia
D
Which of these are signs and symptoms of sepsis? Select all that apply. A. LOC being alert and oriented B. tachycardia C. tachypnea D. dry skin E. shivering and sweaty skin
B, C, E
A patient is admitted with sepsis. As the nurse you understand that all of the following should be completed within the first 3 hours EXCEPT: A. Measure lactate level B. Obtain blood cultures prior to administration of antibiotics C. Apply vasopressors to maintain a MAP of greater than 65 mmHg D. Administer 30 mL/kg crystalloid
C
All of the following are included in the general stages of shock except: A. Initial Stage B. Refractory Stage C. Transitional Stage D. Progressive Stage
C
A patient comes into the ER experiencing septic shock. You assess the patient, what is not a finding that you would expect to see in this patient? a. oliguria b. hypertension c. cool, pale skin d. agitation
B
A patient is admitted to the ED with severe burns. What is the first action the nurse should take? a. Apply cold compresses to the skin b. establish IV access with a large bore needle and hang Lactated Ringer's c. establish IV access with a large bore needle and hang 0.45% NS d. prepare to intubate the patient
B
A patient presents to the emergency department diaphoretic and confused with a mottled appearance to the skin. Upon further assessment, the nurse finds their BP is 90/60, HR is 120, and RR is 36. Based on these signs and symptoms, what is the priority nursing intervention? A. Administer a vasopressor B. Fluid resuscitation C. Obtain a CBC with differential D. Prepare to intubate the patient
B
A patient presents to the emergency department with the following: acidosis, hyperkalemia, and a MAP decrease of 11 mmHg. What general stage of shock is this patient in? a. Initial Stage (early) b. nonprogressive stage (compensatory) c. Progressive stage (intermediate) d. Refractory stage (irreversible)
B
A patient is brought into ED with suspected sepsis. Which organ specific effects would you expect to see. Select all that apply. A. Circulation issues with hypertension due to vasoconstriction B. Respiratory issues with pulmonary edema C. Hepatic dysfunction that allows bacteria and toxins to spill back into the systemic circulation Acute Renal Failure E. Encephalopathy
B, C, D, E
A patient presents to the ED in the Nonprogressive stage of septic shock. What assessment findings would indicate this stage of shock? Select all that apply. a.) Patient has a pH of greater than 7.45 b.) Patient has a potassium less greater than 5.0 c.) The patient's MAP has decreased by 14 mmHg d.) Patient's body no longer responds to interventions e.) Patient has a pH of less than 7.35
B, C, E
The nurse knows that her teaching on the stages of septic shock was effect when the student nurse includes which of the following as part of the non-progressive stage (compensatory)? A.) MAP decreased by 20mmHg B.) Hyperkalemia C.) Acidosis D.) Hypoxia in vital organs E.) Tissue hypoxia in non-vital organs
B, C, E
What characterizes the Nonprogressive Stage of shock? Select all that apply. A. Cell death B. MAP is decreased by 10-15 mmHg or less C. Acidosis D. Hypokalemia E. Tissue hypoxemia in nonvital organs
B, C, E
The preceptor is evaluating the new graduate nurse's level of understanding of the treatment for sepsis. Which of the following correctly identifies the first level of care for a patient who has sepsis? Select all that apply. A. antihistamine therapy B. fluid resuscitation C. administration of blood product D. broad spectrum antibiotics E. high levels of oxygen through a face mask F. initiation of vasopressors G. intubation to begin immediate mechanical ventilation
B, D, F
Which of these interventions is not included in the sepis "bundle"? A. Measure lactate level B. Obtain blood cultures C. Administer heparin D. Administer 30mL/kg crystalloid or lactate > 4mmol/L
C
You are caring for a patient with a recent diagnosis of sepsis, which of the following indicates understanding of the diagnosis? A. "I have an infection in my bones and will need IV fluids and antibiotics" B. "I have a bad bone infection and will need surgery immediately" C. "I have an infection in my blood and will need IV fluids and antibiotics" D. " I have an infection in my blood but it will resolve in 2-3 days"
C
All of the following are symptoms of sepsis, EXCEPT: A. tachycardia B. extreme pain C. sweating D. hypertension E. weakness
D
The nurse is receiving report from the night shift nurse. After hearing about their patients, which patient should the nurse go see first? A. A patient complaining that they want pain medicine B. A patient who has a family member present and asking where the vending machine is C. A patient who had surgery 24 hours ago and needs to go to the restroom D. A patient who's spouse said they seem to be "stressed" because they are breathing quickly, sweating a lot, and look to be shivering some
D
What are the criteria screening assessments using the Quick Sepsis-related Organ Failure Assessment (qSOFA) that clinicians can utilize to identify patients with suspected infection? A. Systolic Hypotension (< 100 mmHg) B. Tachypnea (>22 breaths per minute) C. GCS score of 13 or less D. All of the above
D
Which intervention will the nurse identify as the main goal in the plan of care for a patient in septic shock? A. Assess skin for itching and erythema B. Identify the source of infection C. Auscultate for bowel sounds Q2 D. Restore fluid volume status
D
Which of the following are signs of septic shock? a.) Hypertension and bradycardia b.) Polyuria and polydipsia c.) Hyperthermia and diaphoresis d.) hypotension and tachycardia
D
Which of the following is not a manifestation of septic shock? a) tachycardia b) hypertension c) increased respiratory rate d) hypotension
B
Which of the following is not present during the nonprogressive (compensatory) stage of septic shock? a. Hyperkalemia b. MODS c. Hypoxia in non-vital organs d. Acidosi
B
While caring for a patient diagnosed with sepsis, the nurse understands that which sign and symptom is early and reliable of physiological compromise? a. bradycardia b. tachypnea c. bradypnea d. confusion
B
You're caring for a patient that has developed signs of septic shock. What would you expect the provider to order first? A. RBC infusion B. LR 1000 mL infusion C. Corticosteroids D. Broad spectrum antibiotic
B
Which of the following is NOT used in the treatment of sepsis? A. Crystalloid fluids B. Nitroglycerin C. Vasopressors D. Broad spectrum antibiotics
B
A 34 year old comes to the ED presenting with a MAP decreased by 10-15 mmHG or less, tissue hypoxia in nonvital organs, acidosis, and hyperkalemia. What stage of shock is he in? A) Initial Stage (Early) B) Nonprogressive Stage (Compensatory) C) Progressive Stage (Intermediate) D) Refractory Stage (Irreversible)
B
A nurse is caring for a patient who is experiencing septic shock. What intervention would the nurse anticipate to perform first on this patient? A. Administering oxygen via nasal cannula B. Administering large amounts of IV fluid C. Administer IV antibiotics D. Administer Dobutamine
B
What is the inital sign of sepsis turning into septic shock? a. Hypertension b. Hypotension c. Bradycardia d. Hyperglycemic
B
A nurse is caring for a patient who has developed septic shock. Upon assessment, which finding is most important to report to the provider? A. Cool and clammy skin B. BP of 90/62 C. O2 Sat 92% D. HR 120 BPM
A
A patient is treated in the ED for shock. The first action by the nurse should be to: a. administer oxygen b. attach a cardiac monitor c. obtain the blood pressure d. check LOC
A
A patient that was admitted with a myocardial contusion due to thoracic trauma now presents with tachypnea, tachycardia, and shivering. What do you as the nurse suspect the patient will be diagnosed with? A. Sepsis B. Cardiac Tamponade C. Hemorrhage D. Pulmonary Embolism
A
A registered nurse is educating a student nurse on the organ specific effects of sepsis. The registered nurse knows to correct the student when they state: A) The patient can develop pulmonary edema that could progress to ARDS. B) Fluids are important to fight renal failure. C) The patient will be on blood pressure medication to combat hypertension. D) The pathophysiology behind the sepsis-induced encephalopathy is not well understood.
A
Upon initial assessment of a patient in the ICU, the patient is pale, hypotensive, tachycardic, diaphoretic, has a white blood cell count of 21,000, and a positive blood culture for staph. aureus. What would be your priority intervention for this patient? A. Give isotonic fluids. B. Administer antibiotics. C. Administer atropine. D. Put the patient in a semi-fowlers position.
A
The nurse in the ICU recognizes that her patient is in septic shock. Which of the following would not be performed in the case of sepsis? A. Check lactate levels B. Obtain blood cultures C. Administer diuretics D. Administer broad-spectrum antibiotics
C
A nurse educates a student on the sepsis bundle. What statement by the student shows the teaching was successful? a. within 3 hours hours lactate levels should be measured b. broad spectrum antibiotics do not need to be given until 24 hrs after admission c. antibiotics can be given before blood cultures are taken d. administer 60 ml/kg crystalloid within 3 hours for hypotension
A
A nurse in the ED begins caring for a patient suspected to be in septic shock after a MVA. Which intervention from the nurse will be the most effective for this patient? A. Providing oxygen via simple face mask B. Turning the patient to a left lateral position C. Checking the patient's blood glucose for hypoglycemia D. Administer a 500ml IV bolus of a colloid solution
A
The nurse is assessing the patient in shock and recognizes their MAP has decreased by 20mmHg. Based on her knowledge of the stages of shock, she understands that the patient is in which stage of shock? A. Initial Stage (Early) B. Nonprogressive Stage (Compensatory) C. Progressive Stage (Intermediate) D. Refractory Stage (Irreversible)
C
A client presents to the ED in septic shock, the nurse notices the patient is in the early stage of shock by which two signs? A. diaphoresis and tachycardia B. tachypnea and disorientation c. tachycardia and tachypnea D. fever and extreme discomfort
C
A nurse is caring for a patient in the Nonprogressive (Compensatory) Stage of Septic Shock. Which of the following clinical manifestations would the nurse NOT expect in this stage? a. Tissue hypoxia in non-vital organs b. Acidosis c. Hypokalemia d. MAP decreased by 10-15mmHg Reply Quote
C
A nursing student demonstrates appropriate understanding of organ specific effects of sepsis when she states that bacteria and toxins spilling into the circulatory system is caused by which of the following: a.) Circulatory dysfunction b.) Renal dysfucnction c.) Hepatic dysfunction d.) Respiratory dysfunction
C
A patient presents to the emergency department with a heart rate of 150, tachypnea, sweating, temperature of 102*F, and mild disorientation. Which of the following symptoms is an early sign relating to physiological compromise? a. Anxiety b. Fever c. Tachypnea d. Disorientation
C
A patient with septic shock presents with a urine output of 20ml/hr for the past 4 hours, increased HR and RR, and a MAP decreased by less than 10mm Hg. Which of the following orders by the health care provider will the nurse question? A. Administer Hydrocortisone to treat infection B. Increase normal saline infusion to increase vascular volume to normal range C. Give Furosemide IV D. Adminsiter oxygen in order to maintain tissue oxygenation
C
All of the following are therapy goals for MODS except? a. maintain tissue oxygenation b. increase vascular volume to normal range c. keep the patient in a cold environment d. support compensatory mechanisms
C
IV Norepinephrine was ordered for a patient who is experiencing septic shock. Which statement made my the student nurse indicates further teaching is needed about the use of norepinephrine? A. Norepinephrine is a vasopressor B. It increases BP and cardiac output C. Norepinephrine causes vasodilation D. It causes vasoconstriction
C
All of the following are symptoms of sepsis, EXCEPT: A. hypertension B. high heart rate C. shortness of breath D. diaphoresis
A
A nurse assesses a septic patient and recognizes that the patient has progressed to late septic shock when he exhibits all of the following symptoms EXCEPT: a. anxiety b. cold and pale skin c. oliguria d. severe hypotension
A
A nurse in the ICU is caring for a group of patients at risk for sepsis. Which of the following would put the a patient at the highest risk? A. An 85 year old with an undiagnosed urinary tract infection B. A 55 year old with pericarditis C. A 60 year old with iron deficiency anemia D. A 25 year old with an upper respiratory infection
A
Which finding should the nurse expect while assessing a client with sepsis? A. Bradycardia B. Leukocytosis C. Hypertension D. Hyperthermia
B
A patient was recently admitted to the hospital with a working diagnosis of possible sepsis. As the nurse taking care of the patient you realize the priority action for this patient is: a. administering fluids via IV b. obtaining blood cultures c. administering a broad spectrum antibiotic d. putting the patient under airborne precautions and donning the correct PPE
B
The charge nurse is giving a newly hired nurse a tour of the unit. When discussing sepsis, the new nurse makes the following statements. Which statement requires more teaching? A. "Signs and Symptoms of sepsis include shivering, fever, and the patient being short of breath." B. "A SOFA score of 1 means the patient is experiencing organ dysfunction." C. "Within 6 hours, the patient's lactate should be remeasured if the initial level was elevated." D. "Adjunctive care includes: real replacement therapy, intubation, transfusion, and nutrition."
B
The student lists some specific organ effects from sepsis. Which of the following statements does the nurse recognize as incorrect? A. "The client in sepsis can develop acute renal failure." B. "The septic client can develop COPD." C. "In sepsis, the client will experience hypotension." D. "The liver may stop filtration during sepsis."
B
What life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? A) Fluid volume overload B) Renal insufficiency C) Pulmonary edema D) Gastric stress ulcer
B
What stage of shock is a pt in who's MAP had decreased by 9 mmHg, complaining of chest pain with tachycardia and has an irregular strip. He has not been urinating the past 24 hours and his ABG indicates that he is in metabolic Acidosis. A. Initial stage (early) B. Nonprogressive stage (compensatory) C. Progressive stage (intermediate) D. Refractory stage (Irreversible)
B
When caring for a patient who has septic shock, which of the following assessments is most important for the nurse to report to the health care provider? A. BP is 94/58 mmHg B. Skin is cool and clammy C. Pulse is 120 beats/minute D. Oxygen saturation is 92%
B
A large IV fluid bolus is ordered by the physician and is to be administered to a patient in septic shock. Which status bellow indicates that the treatment was successful? a. Patient's MAP is 35 mmHg. b. Patient's skin is cool and cyanotic. c. Patient's urinary output is 10 mL/hr. d. Patient's blood pressure changes form 76/48 to 110/85.
D
Which of the following is NOT a sign or symptom of the refractory stage in the general stages of shock? A. MODS (multi-system organ dysfunction syndrome) B. Acidosis C. Too little oxygen resulting in cell death D. the body no longer responds to interventions
B
Which of the following is NOT a stage of septic shock? A) Refractory stage B) Progressive stage C) Late stage D) Nonprogressive stage
C
Which of the following is not a sign or symptom of a patient with sepsis? A. fever B. tachypnea C. bradycardia D. diaphoresis
C
Which of the following is not a sign or symptom of sepsis? a) fever b) extreme pain c) hypertension d) shortness of breath
C
Which of the following is not a symptom of sepsis? A. Short of breath B. Clammy and sweaty skin C. Slow heart rate D. Confusion
C
Which of the following is not included in the "first three hours" sepsis bundle? a. Measure lactate level b. Administer broad spectrum antibiotics c. Applying vasopressors d. Obtaining blood cultures prior to administration of antibiotics
C
Which of the following would not be included in the quick sepsis-related organ failure assessment? A. Systolic Hypotension (≤ 100 mm Hg) B. Tachypnea (≥ 22 breaths per minute) C. Bradycardia (< 60 bpm) D. GCS score of 13 or less
C
Which of the following does NOT occur in the initial stage of shock? a) MAP decreases by less than 10mmHg b) HR increases c) RR increases d) Acidosis
D
Which of the following is not a sign of late/severe septic shock? A. hypotension B. decreased urine output C. changes in LOC D. hypertension
D
Which client does the nurse consider to be at highest risk for development of sepsis? A. 75 y/o man with hypertension B. 64 y/o woman 2 days postoperative from bowel surgery C. 80 y/o man with no other health problems undergoing cataract surgery but lives in a community home D. 54 y/o woman with moderate asthma and severe arthritis
B
The nurse is assessing a patient with sepsis. What is a finding associated with patients with sepsis? A. Negative blood cultures B. Initial hypoglycemia C. Tachycardia D. Bradypnea
C
A nurse suspects a patient to be septic. What manifestations would the nurse expect to see? (select all that apply) A. Hypotension B. Confusion C. Tachypnea D. Hypertension E. Bradycardia
A, B, C
While taking care of a septic patient, a nurse understands that which of the following treatment options needs to be done? A. Administer 30mL/kg crystalloid for hypotension or lactate ≥4mmol/L B. Measure lactate level C. Administer broad spectrum antibiotics D. Obtain blood cultures prior to administration of antibiotics E. Wait 50 minutes to preform blood culture prior to administering antibiotics
A, B, C, D
Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply: A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L D. Blood glucose 120 mg/dL E. CVP (central venous pressure) less than 2 mmHg
A, B, C, E
The physician diagnosed a patient with sepsis. Which of the following actions need to be completed within the next 3 hours? Select all that apply. A. Administer 30 mL/kg crystolloid for hypotension. B. Measure lactate level. C. Administer vasopressors. D. Obtain blood cultures then administer broad spectrum antibiotics. E. Administer 50 mL/kg crystalloid for hypotension.
A, B, D
A patient in the ICU is in need of qSOFA screening. This test looks for which characteristics of sepsis related organ failure? (Select all that apply) A. systolic hypotension B. bradycardia C. GCS score of 13 or less D. tachypnea E. fever
A, C, D
What are the goals of sepsis therapy? (Select all that apply). A.) Increase vascular volume B.) Decrease blood pressure with vasodilators C.) Preserve tissue perfusion D.) Aid the body's compensatory mechanisms E.) Prevent a Glascow Coma Scale of higher than 12
A, C, D
What findings should the nurse expect to see while assessing a client with sepsis? (Select all that apply). A. Tachypnea B. Bradypnea C. Shivering D. Tachycardia E. Bradycardia F. Diaphoresis
A, C, D, F
Which of the following are characteristic of sepsis and/or septic shock? Select all that apply. A) Hypotension B) Erythema of the hands C) Tachycardia D) Alkalosis E) Tachypnea
A, C, E
The nurse is assessing a patient for sepsis-related organ failure and the patient receives a SOFA score of 3. What actions within the sepsis bundles should the nurse take within the first 3 hours? Select all that apply. A. administer broad spectrum antibiotics B. obtain blood cultures following the administration of antibiotics C. measure lactate levels D. Administer 30 mL/kg normal saline for hypotension or lactate 4mmol/L or higher
A, C,D
Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Select all that apply. A. Cerebral ischemia B. Fluid Volume overload C. Gastric stress ulcer D. Renal Insufficiency E. Pulmonary edema
A, D
A patient in the hospital is suspected to have developed sepsis. What signs/symptoms would you expect to see in this patient? (select all that apply) A. Diaphoresis B. Seizures C. Bradycardia D. Confusion/Disorientation E. Tachypnea
A, D, E
A patient is in the nonprogressive stage of septic shock. Which of the following might they present with? Select all that apply. A) MAP decreased by 10-15 mmHg or less B) Alkalosis C) Hyperkalemia D) Acidosis E) Tissue hypoxia in nonvital organs F) Bradypnea
A,C,D, E
Which client is most at risk for developing sepsis? A) A 59 year old Type-II diabetic male with a resting blood glucose level of 130. B) An 85 year old female patient who is in the CICU for open heart surgery. C) A 34 year old patient with first degree burns who has no other health problems. D) An 18 year old male who is post-op for a tonsillectomy with a history of Addison's disease.
B
The nurse is assigned to four patients. Which of the following patients is at the highest risk for sepsis? a. A 26-year-old male client recently admitted to the unit with burns on 19% of their body who is experiencing hypothermia and asking for pain medications. b. A 78-year-old female client admitted to the unit with a recently discovered untreated UTI, who is experiencing hypotension, tachycardia and fever and is confused upon arousal. c. A 54-year-old male client who is experiencing tachycardia and hypoglycemia secondary to a pancreatic tumor who is sleeping. d. A 14-year-old female client who experienced a fracture to the clavicle while performing at a cheer competition and is crying, experiencing tachypnea and asking for her parents.
B
What is an early, reliable sign of impending physiological compromise of sepsis? a) Fever b) Tachypnea c) Shivering d) Diaphoresis
B
Which statement below shows that the student nurse correctly understands the general stages in shock?A. MODS (Multi-system organ dysfunction syndrome) is not associated with any stages of septic shock. B. If the shock isn't corrected by the Progressive stage, irreversible damage will be done to the body and the body will no longer respond to treatment if the patient enters the refractory stage. C.The Refractory stage is known as the emergent stage where action must be taken before it reaches the Progressive stage, which is where irreversible damage occurs. D. All stages of septic shock is reversible and it is not a medical emergency.
B
f a patient presents to the hospital and is in the Nonprogressive stage of shock, the nurse would understand that the patient would be experiencing which of the following? A. HR and RR increase B. Hyperkalemia and tissue hypoxia in nonvital organs C. Multi-system organ dysfunction syndrome D. Tissue hypoxia in vital organs
B
You are providing care to 4 clients. Identify the clients who are at risk for developing sepsis. (Select all that apply): A: A 42-year-old female who is being treated for stage 4 breast cancer undergoing chemo. B: A 63-year-old male who is recovering from a kidney transplant surgery. C: A 36-week old preemie with an ET Tube, Foley catheter and a central line. D: A 55-year-old male with chronic alcoholism recovering from surgery.
B, C
In regards to pathophysiology of sepsis, what statement is accurate? A. A surge of pro-inflammatory cytokines causes an immediate apoptosis of neutophils B. An increase in lymphocytes due to apoptosis shortens the inflammatory response by the body C. Host defense cells as stimulated resulting in systemic inflammation and activation of pro-inflammatory mediators leading to tissue damage D. Increased coagulation and appropriate deposition of intravascular fibrin Reply Quote
C
The nurse assessing a patient in sepsis in the ICU and wants to find out how the patient is responding to treatment. What laboratory test would be most appropriate in determining this? A. CBC B. BUN and creatinine C. lactate D. AST and ALT
C
The nurse correctly identifies which of the following patients as at the greatest risk for developing sepsis. a. A patient 2 days post-op with a clean, dry incision site without any drainage b. A patient in the ICU with a qSOFA score of 1 c. A patient that has a pressure ulcer on their heel with a fever and a diagnosis of type 2 diabetes with poorly controlled blood sugar d. A patient about to be discharged to an Long Term Acute Care unit 5 days post chest tube removal without complications
C
The nurse is assessing their patient who was admitted for a UTI three days prior. Which of the following vital signs would cause the nurse to suspect that the patient may be going into sepsis? A) A respiratory rate of 14 and a heart rate of 82 bpm B) A temperature of 98.6 degrees F and a respiratory rate of 10 C) A blood pressure of 76/58 and a heart rate of 120 bpm D) An O2 saturation of 94% and a blood pressure of 140/96
C
The nurse is caring for a 53 year old male patient who is in shock. Which intervention would the nurse question? A) Administer Fluids (Crystalloid 30ml/kg) to correct hypotension B) Administer Broad spectrum antibiotics to destroy bacteria in the blood C) Administer Narrow spectrum antibiotics to destroy a specific bacteria in the blood D) Begin treatment by adminstering norepinephrine to increase vasoconstriction
C
The nurse is caring for a client with a severe infection develops sepsis. Which of the following are expected findings of a patient with sepsis? a.) bradypnea, diaphoresis, bradycardia, hypertension b.) bradypnea, dry skin, bradycardia, hypotension c.) tachypnea, diaphoresis, tachycardia, hypotension d.) tachypnea, dry skin, tachycardia, hypertension
C
The nurse is teaching a nursing student about the general stages of shock, which statement made by the student indicates understanding of the Progressive stage? A. "This stage of shock is considered irreversible." B. "This stage is not considered an emergency because MAP has only decreased by 20 mmHg." C. "The patient will lose oxygenation to their brain." D. "EKG changes will occur because the patient experiences hyperkalemia in this stage."
C
