Sepsis
a (Mr. Hafner has a history and clinical manifestations that are consistent with septic shock. When SIRS is severe, sepsis develops and the risk of simultaneous bleeding and clotting throughout the vasculature, called disseminated intravascular coagulation (DIC) is increased. Sepsis injures blood cells, which can cause platelet aggregation and decreased blood flow, resulting in clots throughout microcirculation and leading to septic shock.)
Mr. Hafner is a 43-year-old man recovering from a ruptured diverticulum. His vital signs are as follows: Temperature 102.2 °F, HR 120 beats/minute, BP 79/42 mmHg, and respiratory rate 24/minute. Upon examination you notice that he is confused, his skin is cool and pale, and there is a small amount of bleeding around his IV site. What would you expect Mr. Hafner's blood test to reveal? a Disseminated intravascular coagulation (DIC) b Systemic inflammatory response syndrome (SIRS) c Multiple-organ dysfunction syndrome (MODS) d Deep vein thrombosis (DVT)
1 (The LPN can administer IV antibiotic medication according to the LPN scope of practice. The UAP should be instructed to empty the cath LPN cannot assess or evaluate)
10 Which task is most appropriate for the surgical nurse to assign to the LPN? 1. Tell the LPN to administer the aminoglycoside antibiotic to the client 2. Request the LPN empty the clients indwelling urinary cath 3. Instruct the LPN to assess the client who was just transferred from PACU 4. Ask the LPN to determine if the client understands the discharge teaching
3 ( The most common complication of too-rapid IV infusion of fluids is volume overload leading to heart failure. Although peripheral edema, decreased urine output, and jugular venous distention may be indicators that heart failure is developing, they do not occur as rapidly as the backup of fluids into the pulmonary capillaries and then into the alveoli. Focus: Prioritization)
10. When you are infusing the normal saline, which action is most important in evaluating for an adverse reaction to the rapid fluid infusion? 1. Palpating for any peripheral edema 2. Monitoring urine output 3. Listening to lung sounds 4. Checking for jugular venous distention
2 ( A nontender lump in this area (or near any lymph node) may indicate that the patient has developed lymphoma, a possible adverse effect of immunosuppressive therapy. The patient should receive further evaluation immediately. The other symptoms may also indicate side effects of cyclosporine (gingival hyperplasia, nausea, paresthesia), but do not indicate the need for immediate action. Focus: Prioritization)
22. A patient who has been receiving cyclosporine (Sandimmune) following an organ transplantation is experiencing the following symptoms. Which one is of most concern? 1. Bleeding of the gums while brushing the teeth 2. Nontender lump in the right groin 3. Occasional nausea after taking the medication 4. Numbness and tingling of the feet
3 (The urinalysis showing many bacteria is indicative of infection. Clients receiving chemo are at high risk for developing infection. Notify the HCP immed. Elevated amylase expected in acute pancreatitis. Elevated WBC expected in septic leg Elevated glucose not particulary abnormal with diabetes)
31 which client lab data should the nurse report to the HCP immediately? 1. The elevated amylase report on a client dx with acute pancreatitis 2. The elevated WBC count on a client dix with a septic leg wound 3. the urinalysis report showing many bacteria in a client receiving chemotherapy 4 The serum glucose level of 235 on a client dx with Type I diabetes
1 (common surgical procedure and not experiencing complication. The least experienced can care for this client. 2. Green bile in T tube expecte, gray indicates infection. 3. popping means possible dislocation 4. Whipple involves removing most of pancreas. Symptoms indicate the client is not metabolizing glucose)
59 The charge nurse is making assignments on a surgical unit. Which client should be assigned to the least experienced nurse? 1 The client who had a vaginal hysterectomy and still has an indwelling catheter 2. The client with an open cholecystectomy and has gray drainage in the tube 3. The client who had a hip replacement and states something popped while walking 4. The client who had a Whipple procedure and reports being thirsty all the time
a (Rationale The most common cause of bacterial sepsis is gram-positive infections from Staphlococcus and Streptococcus bacteria. The incidence of gram-negative bacterial infections has increased since 2003 with a 60% mortality rate despite treatment. This incidence has increased the most in older adults and non-White populations due to an increase in invasive procedures, immunosuppressive therapies, and antimicrobial resistance. Clients at risk for developing sepsis related to infections are those clients who are hospitalized, have debilitating chronic illnesses, have poor nutritional status, are post invasive procedure or surgery, are older adults, and those who are immunocompromised.)
A nurse assigned to the intensive care unit (ICU) should closely monitor which client who is at most risk for septic shock? a A 66-year-old female with infectious pneumonia b A 22-year old male with spontaneous pneumothorax c A 46-year old female with mitral valve prolapse d A 34-year old male with a traumatic head injury
2 ( The oxygen saturation indicates that the patient is severely hypoxic (despite an increased respiratory rate). Because this hypoxia will affect all other body systems, it should be treated immediately. The other orders also should be rapidly implemented, but they do not require action as urgently as the low oxygen saturation. Focus: Prioritization)
Blood pressure 102/38 mm Hg Heart rate 102 beats/min O2 saturation 76% Respiratory rate 40 breaths/min Temperature 102.4° F (39.1° C) (orally) 1. Based on the initial history and assessment, which action prescribed by the health care provider (HCP) will you implement first? 1. Insert a Foley catheter and send a urine specimen for culture and sensitivity testing. 2. Start oxygen and titrate to maintain oxygen saturation at 90% or higher. 3. Place the patient on a cardiac monitor. 4. Check the blood glucose level.
4 ( The low blood pressure indicates that systemic tissue perfusion will not be adequate, so measures to improve the blood pressure need to be implemented rapidly. The second priority is to treat the infection that is a likely cause of the temperature elevation and hypotension. The crackles heard in the patient's left lung do not need immediate intervention, because her oxygen saturation is 93%. The nonpalpable pedal pulses are associated with the hypotension and will improve if blood pressure is increased. Focus: Prioritization)
Blood pressure 86/40 mm Hg Heart rate 112 beats/min O2 saturation 93% Respiratory rate 32 breaths/min Temperature 103° F (39.4° C) (axillary) 7. Which information in your assessment requires the most immediate action? 1. Elevated temperature 2. Left lung crackles 3. Nonpalpable pulses 4. Low blood pressure
2 ( The elevated glucose level will require that you administer the ordered insulin lispro using the hospital standard sliding-scale insulin orders. Potassium will move into cells along with glucose as insulin is administered, so the patient's potassium level does not require additional treatment. The other abnormalities indicate the need for continued monitoring, but will not require any immediate action at this time. Focus: Prioritization)
Hematocrit 32% Hemoglobin level 10.9 g/dL Platelet count 96,000/mm3 White blood cell count 26,000/mm3 Blood urea nitrogen level 56 mg/dL Creatinine level 2.9 mg dL Glucose level 330 mg/dL Potassium level 5.2 mEq/L Sodium level 140 mEq/L 15. Which laboratory value requires the most immediate action? 1. Creatinine level 2. Glucose level 3. Potassium level 4. Hemoglobin level
2 (An Iv antibiotic is the priority medication for the client with an infection, which is the definition of sepsis. A systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within 1 hour of receiving the order.)
The client diagnosed with septicemia has the following HCP orders. Which HCP order has the highest priority? 1. Provide clear liquid diet 2. Initiate IV antibiotic therapy 3. Obtain stat chest x ray 4. Perform hourly glucometer checks
a (Sepsis injures blood cells, which can cause platelet aggregation and decreased blood flow, resulting in clots throughout microcirculation and leading to septic shock. This progression of sepsis leads to reduced organ perfusion and multiple-organ dysfunction syndrome (MODS) and ultimately death.)
The progression of sepsis leads to reduced organ perfusion and eventually which syndrome? a Multiple-organ dysfunction syndrome (MODS) b Systemic shock syndrome (SSS) c Systemic inflammatory response syndrome (SIRS) d Toxic shock syndrome (TSS)
a (Gastric tonometry and sublingual PaCO2 are newer diagnostic methods that measure the partial pressure of carbon dioxide in the gastric lumen (sublingual CO2 correlates with decreased mean arterial pressure).)
Which diagnostic test measures partial pressure of CO2 in the gastric lumen? a Sublingual PaCO2 b Gastric CT c Endoscopic exam d Echocardiogram
1, 2, 6 ( Checking vital signs and urine output is included in UAP education. Experienced UAPs will know which patient information to report immediately to the supervising RN. UAPs working in the ED setting would also have been trained and know how to establish cardiac monitoring, although dysrhythmia analysis and treatment would be the responsibility of the RN. Obtaining and documenting assessments and starting an IV line should be done by the RN. Focus: Delegation)
3. Available staffing in the ED includes you and an experienced UAP. Which actions will be best for you to delegate to the UAP? (Select all that apply.) 1. Measuring vital signs every 15 minutes 2. Attaching the patient to a cardiac monitor 3. Documenting a head-to-toe assessment 4. Checking orientation and alertness 5. Inserting an IV line 6. Monitoring urine output hourly
4 (The LPN can administer routine medications for clients who have no life threatening conditions. #1 client in crisis should be assigned to RN #2 Biliary atresia involves liver failure and multiple body systems. This client should be assigned to RN #3 Anaphylaxis is an emergency situation, assign to RN)
64 The charge nurse is making assignments on a pediatric unit. Which client should be assigned to the LPN? 1. The 6 year old dx with sickle cell crisis 2. The 8 year old dx with biliary atresia 3. The 10 year old dx with anaphylaxis 4. The 11 year old dx with pneumonia
b,c,e (Rationale For the client with sepsis, nursing interventions are aimed at improving tissue perfusion because diminished tissue perfusion causes ischemia and hypoxia of major organ systems. Monitor the client's cardiopulmonary function by assessing/monitoring all vital signs. Monitor urinary output; this is a reliable indicator of renal perfusion.Assess the client's mental status and level of consciousness. Appropriateness of responses and behavior reflects the adequacy of cerebral circulation. Altered LOC is a result of cerebral hypoxia and the effects of acidosis on brain cells.)
A nurse assigned to the intensive care unit is caring for a client diagnosed with septic shock. Which nursing interventions should the nurse include in the client's plan of care to anticipate complications of shock? (Select all that apply.) a Encourage the client to perform mobility exercises b Monitor fluid status with intake and output c Assess the client's mental status d Provide emotional support to the client and family e Monitor client's blood pressure and pulse
a (Mr. Ikaika appears to be in septic shock. Appropriateness of responses and behavior reflects the adequacy of cerebral circulation, and an elevated temperature increases metabolic demands, depleting bodily energy reserves, increasing myocardial oxygen demands, and increasing the risk of hypoperfusion. Therefore, it is important to improve tissue perfusion because diminished tissue perfusion causes ischemia and hypoxia of major organ systems (significantly the kidneys, brain, heart, lungs, and gastrointestinal tract).)
Mr. Ikaika, a 68-year-old man with a history of diabetes mellitus, is admitted with an infected diabetic foot ulcer. Upon admission you notice that he is confused and his vital signs are: temperature 102.6 °F, blood pressure 81/39 mmHg, and pulse 55. Which nursing diagnosis is indicative of his symptoms? a Ineffective tissue perfusion b Imbalanced fluid volume c Ineffective metabolic status d Impaired nutritional status
4 (A new antibiotic must be initiated as soon as possible, at least within one hour. A broad spectrum is ordered until C&S results are determined, Then an antibiotic which will specifically target the infectious organism must be started immed.)
The nurse administers an IV broad spectrum antibiotic scheduled every 6 hrs to the client with systemic infection at 0800. At 1000 the culture and sensitivity promted the HCP to change the IV antibiotic. When transcribing the new antibiotic order, when would the initial dose be administered? 1. Schedule dose for 1400 2. Schedule dose for the next day 3. Check with the HCP to determine when to start 4. Administer the dose within 1 hr of the order
3 (Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion can be caused by hemorrhage as in hypovolemic shock; decreased cardiac output as in cardiogenic shock; or massive vasodilation of the vascular bed as in neurogenic shock; anaphylactic and septic shock. Fluid deficit, not overload occurs in shock)
What is the most important goal of nursing care for a client in shock? 1. Manage fluid overload 2. Manage increased cardiac output 3. Manage inadequate tissue perfusion 4. Manage vasoconstriction of vascular beds
2 ( A nonrebreather mask can provide a fraction of inspired oxygen (Fio2) of close to 100%, which will be needed for this severely hypoxemic patient. Nasal cannulas deliver a maximum Fio2 of 44%, simple face masks deliver an Fio2 of up to 60%, and Venturi masks provide a maximum Fio2 of 55%. Focus: Prioritization)
Blood pressure 102/38 mm Hg Heart rate 102 beats/min O2 saturation 76% Respiratory rate 40 breaths/min Temperature 102.4° F (39.1° C) (orally) 2. Which method of oxygen administration will be best to increase Ms. D's oxygen saturation? 1. Nasal cannula 2. Nonrebreather mask 3. Venturi mask 4. Simple face mask
d (Rationale When assessing a client with sepsis, the nurse monitors the client's hemodynamic status with a central venous pressure IV line or pulmonary artery catheter. Normal CVP is 2-8 mmHg and is decreased with septic shock.)
The nurse is concerned that a client admitted to the cardiac care unit (CCU) after a motor vehicle crash is demonstrating signs of septic shock. Which assessment finding supports this concern? a O2 saturation of 92% b Pulse 60 c Blood pressure 110/72 d CVP is 1
a,c,d,e (Portals of entry for infection that may lead to sepsis include, but are not limited to, intravenous catheters, surgical wounds, sexually transmitted infections, and peptic ulcerations. Pulse oximetry is not an invasive procedure and is not a portal of entry for infectious sepsis.)
A client is at risk for infectious sepsis through which portals of entry? (Select all that apply.) a Intravenous catheters b Pulse oximetry monitoring c Sexually transmitted infections d Surgical wounds e Peptic ulcerations
1, 3, 4, 5, 6, 7 ( The decreased blood pressure and increased heart rate are indicators of shock. The elevation in temperature suggests that sepsis (and massive vasodilation) may be the cause of the shock. The blood-streaked and cloudy urine, and back and abdominal pain point to a urinary tract infection (UTI) and/or pyelonephritis as the cause of the sepsis. Diabetic patients are at increased risk for UTI and sepsis. Atrial fibrillation is not an indicator of sepsis and is unlikely to be the cause of Ms. D's hypotension. Focus: Prioritization)
8. Ms. D is admitted to the intensive care unit (ICU) with a diagnosis of probable sepsis and septic shock. Which data that you have collected in the health history and physical assessment are significant in developing and confirming the diagnoses of sepsis and septic shock? (Select all that apply.) 1. Increased temperature 2. Atrial fibrillation rhythm 3. Cloudy, blood-streaked urine 4. Decreased blood pressure 5. Elevated heart rate 6. Abdominal and back pain 7. History of diabetes mellitus
3 4 1 5 2 ( Guidelines from the national Surviving Sepsis campaign suggest that the first action should be fluid infusion, because Ms. D's minimal urine volume and history of not taking in fluids indicate that she is hypovolemic. In addition, sepsis is associated with massive vasodilation, which leads to hypotension and decreased tissue perfusion, so increasing the circulating volume is essential for this patient. The norepinephrine infusion should be started next to counteract the circulatory vasodilation. The blood for culture (and specimens for any other ordered cultures) should be obtained before the antibiotics are started. All of these orders should be implemented rapidly, because septic shock quickly leads to multiple organ dysfunction syndrome, which is usually fatal. FIRST: Fluids with low urine output/hypotension in septic shock SECOND: Vasopressor to address hypotension THIRD: BLOOD CULTURES to determine best antibiotic FouRTH: Get the antibiotic on board! Last: Tylenol to address high temp)
9. Because the ICU is short-staffed, the nursing supervisor assigns you to follow Ms. D to the ICU and care for her there. In which order will you implement these interventions that have been prescribed by the HCP? (pt has low BP, low urine output) 1. Draw blood for culture from three separate sites. 2. Administer acetaminophen (Tylenol) 650 mg rectally. 3. Infuse normal saline at 1,000 mL/hour until systolic blood pressure (SBP) is 90 mmHg 4. Titrate norepinephrine (Levophed) infusion at 1-4 mcg/minute to keep the systolic blood pressure (SBP) at 90 mmHg 5. Give vancomycin (Vancocin) 1 gram intravenously every 12 hours.
a,c,e (Rationale Gastric tonometry and sublingual PaCO2 are newer diagnostic methods that measure the partial pressure of carbon dioxide in the gastric lumen to help identify the cause of sepsis and assess the client's physical status. Other diagnostic tests include X-ray, CT scan, MRI scan, endoscopic exams, and echocardiograms)
A client is brought to the emergency department following a motor vehicle crash. What diagnostic tests should you anticipate the healthcare provider ordering to help determine risk for shock?(Select all that apply.) a CT scan b Cardiac catheterization c MRI d Electromyography e Gastric tonometry
a (Rationale The priority pharmacologic therapy for a client with sepsis is the administration of a broad-spectrum antibiotic. Antimicrobials are the primary pharmacologic treatment for sepsis. Vasoactive and inotropic medications are considered if fluid replacement is not effective. Opioid medications may be given for comfort, but this is not the priority.)
A client is brought to the emergency department for treatment of possible sepsis. Which pharmacologic therapy is a priority for this client? a Broad-spectrum antibiotics b Inotropic medications c Vasoactive medications d Opioid medications
2 ( The ABG values indicate that the patient is hypoxemic (low Pao2 and oxygen saturation) and has a severe uncompensated respiratory acidosis (low pH and elevated Paco2). Because she is unable to maintain adequate oxygenation and ventilation independently, intubation and mechanical ventilation are indicated. Sodium bicarbonate is administered only if metabolic acidosis is present. Although the patient will need ongoing respiratory monitoring and may also benefit from albuterol therapy, these therapies are not adequate in a patient with these severe ABG abnormalities. Focus: Prioritization)
Arterial partial pressure of carbon dioxide (Paco2) 62 mm Hg Arterial partial pressure of oxygen (Pao2) 50 mm Hg Bicarbonate (HCO3−) 22 mEq/L O2 saturation 87% pH 7.23 5. Based on your analysis of these ABG values, which collaborative intervention do you anticipate? 1. Sodium bicarbonate (NaHCO3) bolus IV 2. Endotracheal intubation and mechanical ventilation 3. Continuous monitoring of Ms. D's respiratory status 4. Nebulized albuterol (Proventil) therapy
4 (Antipyretic medications will help decrease the fever, which directly addresses the etiology of the nursing diagnoses.)
The nurse caring for the client with sepsis writes the client diagnoses of alteration in comfort R/T chills and fever. Which intervention should be included in the plan of care? 1. Ambulate the client in the hall way every shift 2. Monitor urinalysis, creatinine level and BUN level 3. Apply sequential compression devices to the LE 4. Administer an antipyretic medication every 4 hrs PRN
c (Rationale Arterial blood gas (ABG) test results in clients with septic shock will indicate a decrease in pH (indicating acidosis), a decrease in PaO2 and total oxygen saturation, and an increase in PaCO2.)
The nurse is caring for a client diagnosed with septic shock. Which arterial blood gas (ABG) finding would indicate that the client is in shock? a Decreased CO2 level b Decreased PaCO2 c Decreased pH level d ncreased O2 level
2 (Warm flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other s/s of early septic shock include fever with restlessness and confusion; normal or decreased BP with tachypnea and tachycardia; increased or normal urine output; and N/V or diarrhea. Cool clammy skin occurs in hypodynamic or cold phase (later phase) Hemorrhage is not a factor in septic shock)
When assessing a client for early septic shock, the nurse should assess the client for which finding? 1. cool clammy skin 2. warm flushed skin 3. increased BP 4 hemorrhage
3 ( Because the decrease in oxygen saturation will have the greatest immediate effect on all body systems, improvement in oxygenation should be the priority goal of care. The other data also indicate the need for rapid intervention, but improvement of oxygenation is the most urgent need. Focus: Prioritization)
10. A patient is admitted to the intensive care unit with disseminated intravascular coagulation associated with a gram-negative infection. Which assessment information has the most immediate implications for the patient's care? 1. There is no palpable radial or pedal pulse. 2. The patient reports chest pain. 3. The patient's oxygen saturation is 87%. 4. There is mottling of the hands and feet.
2 (The shift manager should have objective data about the allegation prior to confronting the UAP)
11 The primary nurse informs the shift manager that one of the UAPs is falsifying VS. Which action should the shift manager implement first? 1. Notify the unit manager of the potential situation of falsifying VS 2. Take the assigned clients VS and compare to the UAPs results 3. Talk to the UAP about the primary nurses allegation 4. Complete a counseling record and place in the UAPs file
4 ( Any temperature elevation in a neutropenic patient may indicate the presence of a life-threatening infection, so actions such as drawing blood for culture and administering antibiotics should be initiated quickly. The other patients need to be assessed as soon as possible but are not critically ill. Focus: Prioritization)
12. You receive a change-of-shift report about the following patients. Which one will you assess first? 1. 26-year-old with thalassemia who has a hemoglobin level of 8 g/L and orders for a PRBC transfusion 2. 44-year-old who was admitted 3 days previously in a sickle cell crisis and has orders for a computed tomographic scan 3. 50-year-old with stage IV non-Hodgkin lymphoma who is crying and saying, "I'm not ready to die" 4. 69-year-old with chemotherapy-induced neutropenia who has an oral temperature of 100.1° F (37.8° C)
1, 4 ( LPNs/LVNs are educated and licensed to perform tasks such as monitoring and documenting intake and output, bedside blood glucose monitoring, and administering insulin under the supervision of an RN. Although LPNs/LVNs can collect data about patients, actions such as administering IV antibiotics to critically-ill patients and monitoring for therapeutic and adverse effects of vasoactive medications require more education and RN-level skill. Focus: Delegation)
13. You are working with an experienced LPN/LVN in caring for Ms. D. Which nursing activities included in the care plan should be delegated to the LPN/LVN? (Select all that apply.) 1. Documenting the nasogastric tube drainage and urinary output on the ICU flow sheet 2. Notifying the laboratory after giving gentamicin so that gentamicin peak level can be measured 3. Monitoring the dopamine infusion site for signs of extravasation 4. Administering sliding-scale insulin lispro subcutaneously every 6 hours 5. Completing and documenting a head-to-toe assessment every 4 hours 6. Monitoring blood pressure and titrating dopamine to keep systolic pressure at 100 mm Hg
1 (Because the client is IN the preop area the immediate safety need for the client is to inform the OR personnel so that no latex gloves or equipment come into contact with the client. Person to person communication for a safety issue ensures information is not overlooked. The other interventions performed after this is done)
15 The female client in the preop holding area tells the nurse that she had a reaction to a latex diaphragm. Which intervention should the nurse perform first? 1. Notify the operating room personnel 2. Label the clients chart with the allergy 3. place a red allergy band on the client 4. Inform the HCP of the allergy
4 (The UAP can add up the urine output for the 12 hr shift, however the nurse is responsible for evaluating whether the urine output is what is expected for the client. #1 is not an accucheck or capillary glucose, it is one that requests serum glucose which is done via venipuncture... )
16 The nurse, ,a LPN, and the UAP are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? 1. Instruct the UAP to obtain the clients serum glucose level 2. Request the LPN to change the central line dressing 3. Ask the LPN to bathe the client and change the bed linens 4. Tell the UAP to obtain urine output for the 12 hr shift
2 (The UAP can take specimens to the lab, it is not medications and not vital to client A client on the ventilator is not stable, Addisonian crisis is not stable, and UAP cannot assist the HCP with an invasive procedure at bedside)
17 Which task should the critical care nurse delegate to the UAP? 1. check the pulse oximeter for the client on a ventilator 2. Take the clients sterile urine specimen to the lab 3. Obtain the VS for the client in an addisonian crisis 4. Assist the HCP in performing paracentesis at bedside
2 ( Because the spleen has an important role in the phagocytosis of microorganisms, the patient is at higher risk for severe infection after a splenectomy. Medical therapy, such as antibiotic administration, is usually indicated for any symptoms of infection. The other information also indicates the need for more assessment and intervention, but prevention and treatment of infection are the highest priorities for this patient. Focus: Prioritization)
17. The nurse in the outpatient clinic is assessing a 22-year-old who required a splenectomy after a recent motor vehicle accident. Which information obtained during the assessment will be of most immediate concern to the nurse? 1. The patient engages in unprotected sex. 2. The oral temperature is 100° F (37.8° C). 3. There is abdominal pain with light palpation. 4. The patient admits to occasional marijuana use.
2
18 The critical care nurse is making assignments. Which client should the charge nurse assign to the nurse who is pregnant? 1 The client with intracavity radiation for cervical cancer who developed ARDS 2. The client who is HIV positive and admitted for R/O myocardial infarction 3. The client who is immunosuppressed with Dx CMV 4 The client receiving I131 iodine for hyperthyroidism who had a MVA
4 (The client is exhibiting signs of DIC which requires IV therapy This is life threatening complication that requires immediate intervention so the nurse must notify the HCP first)
19 The ICU nurse is caring for a client and notes blood oozing out from under the Tegaderm dressing over the peripheral IV site, bleeding gums, and blood in the indwelling urinary catheter bag. Which intervention should the nurse implement first? 1. Check the H/H level 2. monitor the clients pulse oximeter reading 3. Apply pressure to the IV site 4. Notify the HCP
3 (of the 4 clients this is the most stable.)
9. The charge nurse making assignments for the surgical unit. Which client should be assigned to the new graduate nurse? 1. The 84 year old who has a chest tube that is draining bright red blood 2. the 38 year old client who is 1 day post op with a temp of 101.2 F 3. The 42 year old client who has just returned after a breast biopsy 4. The 55 year old client who is complaining of unrelenting abd pain
d (Rationale Toxic shock syndrome is a virulent form of septic shock that occurs most frequently in menstruating women who use tampons incorrectly. Bacterial toxins from the vagina diffuse into circulation and cause widespread inflammatory response and septic shock. Clinical manifestations of toxic shock syndrome include extreme hypotension, hyperpyrexia, headache, myalgia, confusion, skin rash, vomiting, and diarrhea.)
A client is brought to the emergency department for treatment of possible toxic shock syndrome. Which manifestation should the nurse anticipate when assessing this client? a Hyperactive bowel sounds b Elevated blood pressure c Anorexia d Vomiting
1 (The nurse monitors the blood levels of antibiotics, WBCs, serum creatinine, and BUN because of the decreased perfusion of the kidneys, which are responsible for filtering out the ceftriaxone sodium. It is possible that the clearance of the antibiotic has been decreased enough to cause toxicity. Increased levels of these laboratory values should be reported to the HCP immediately. A spinal fluid analysis is done to examine CSF but there is no indication of CNS involvement in this case. ABGs are used to determine actual blood gas levels and assess acid base imbalance. Serum osmalality is used to monitor F/E balance)
A client with toxic shock has been receiving ceftriaxone sodium, 1 g every 12 hours. In addition to culture and sensitivity studies, what other laboratory findings should the nurse monitor? 1. serum creatinine 2. spinal fluid analysis 3. arterial blood gases 4. serum osmolality
3 ( The decrease in PA wedge pressure indicates that the patient is still hypovolemic and will need an increase in IV fluids. The arterial blood pressure is improved, and you already have an order to increase the dopamine if needed. The atrial fibrillation rate is not dangerously elevated. Although the patient's temperature still is elevated, it has decreased from the previous reading. Focus: Prioritization)
Blood pressure 104/56 mm Hg Heart rate 104 beats/min (atrial fibrillation) O2 saturation 95% PA systolic pressure 15 mm Hg (normal = 15 to 30 mm Hg) PA diastolic pressure 2 mm Hg (normal = 4 to 12 mm Hg) PA wedge pressure 2 mm Hg (normal = 6 to 12 mm Hg) Respiratory rate 26 breaths/min Temperature 101.6° F (38.7° C) (rectal) 14. Which information about Ms. D is most important for you to communicate rapidly to the intensivist? 1. Decreased blood pressure 2. Ongoing atrial fibrillation 3. Low PA wedge pressure 4. Continued temperature elevation
a (Ms. Smith is an adult client who has received antibiotic therapy and has had a prolonged recovery in a critical care unit. Fluid replacement is the most effective treatment for septic shock (either IV fluids or blood) and can be used alone or in combination with other treatments. Blood and blood products increase oxygenation of cells and crystalloid and/or colloid solutions increase circulating blood volume and tissue perfusion.)
Ms. Smith is a 54-year-old woman admitted to the critical care unit 2 days ago with community-acquired pneumonia and respiratory failure. Although she has been on antibiotics, she is requiring increased amounts of oxygen and is diagnosed with sepsis. Which therapy would be the most effective for Ms. Smith at this time? a NS @ 125 mL/hr b Lasix 40 mg IV q 12 hours c Morphine 2 mg IV q 2hours d Keflex 80 mg IVP q 6 hours
4 (A sensitivity report indicating resistance to the antibiotic being administered indicates the medication this client is receiving is not appropriate for treatment, and the HCP needs to be notified so the antibiotic can be changed.)
The client diagnosed with septicemia is receiving a broad spectrum antibiotic. Which laboratory data require the nurse to notify the HCP? 1. The clients potassium level is 3.8 2. The urine culture indicates high sensitivity to the antibiotic 3. The clients pulse oximeter reading is 94% 4. The culture and sensitivity is resistant to the clients antibiotic
1 (The hypodynamic phase is the last and irreversible phase of septic shock, characterized by low cardiac output, with vasoconstriction. It reflects the bodys effort to compensate for hypovolemia caused by the loss of intravascular volume through the capillaries. In the compensatory stage of shock the HR, BP, and RR are wnl. but the skin may be cold clammy and urinary output may be decreased. However this is the first phase of all types of shock and is not specific to septic shock In the hyperdynamic phase, the first phase of septic shock is characterized by a high cardiac output with systemic vasodilation. The BP may remain wnl, but the HR increases to tachycardia and the client becomes febrile. The progressive phase is the second phase of all shocks. It occurs whey the systolic BP decreases to less than 80-90, the HR increases to greater than 150 bpm and the skin becomes mottled.)
The nurse caring for a client diagnosed with septic shock who has hypotension, decrease urine output, and cool pale skin. Which phase of septic shock is the client experiencing? 1. They hypodynamic phase 2 The compensatory phase 3. The hyperdynamic phase 4. The progressive phase
3 (Anytime a nurse administers a medication for the first time, the client should be observed for a possible anaphylactic reaction especially with antibiotics)
The nurse in the ED administered an IM antibiotic in the L gluteal muscle of teh client with pneumonia who is being discharged home. Which intervention should the nurse implement? 1. Ask the client about drug allergies 2. Obtain sterile sputum specimen 3. Have the client wait 30 mins 4. Place a warm washcloth on the clients left hip
3 (The client must have urinary output of at least 30 mL/hr so 90 would indicate impaired renal perfusion which is a sign of worsening shock. The other options are expected with septic shock)
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1 VS T 100.4, P 104, RR 26, and BP 102/60 2. A WBC count of 18000 3. A urinary output of 90 mL in the last 4 hours 4. The client complains of being thirsty
b (Rationale Oliguria and hypotension are considered part of the cold phase or late septic shock. In this phase, in addition to blood pressure and urine decreases, hypovolemia and compensatory mechanisms result, such as rapid, shallow, or dyspneic respirations. The skin becomes cool, pale, and edematous; the client becomes lethargic to comatose mental status. There is decreased CVP, tachycardia, and arrhythmic pulses, and normal to decreased body temperatures. Death may occur during this phase due to respiratory, cardiac, and/or renal failure.)
The nurse is caring for a client diagnosed with septic shock. Which assessment finding should the nurse report immediately to the healthcare provider? a Hyperactive bowel sounds with abdominal distention b Urine output of 15 mL/hr and BP of 82/45 c Bradycardia with an elevated temperature of 102.4degreesF d Elevated blood pressure and warm, dry skin
a,d,e (Rationale Assess the client's mental status and level of consciousness. Appropriateness of responses and behavior reflects the adequacy of cerebral circulation. Restlessness and anxiety are common signs of early septic shock; lethargy and coma progression reflect later stages. Altered LOC is a result of cerebral hypoxia and the effects of acidosis on brain cells.)
The nurse is caring for a client diagnosed with septic shock. Which neurological assessment findings require immediate nursing interventions? (Select all that apply.) a Disorientation b Hypothermia c Acidosis d Restlessness e Lethargy
a (Rationale A blood culture will determine specific pathogens and be useful for prescribing antibiotics that are the most effective to treat the sepsis. Arterial blood gases monitor oxygenation status. Serum enzymes determine liver damage. Serum electrolytes determine potassium levels.)
The nurse is caring for a client with sepsis. The client's family asks the nurse why there is a need for a blood culture when a diagnosis has already been issued. Which response by the nurse is the most appropriate? a The blood culture determines the most appropriate antibiotics. b The blood culture monitors potassium levels. c The blood culture determines if liver damage is occurring. d The blood culture will allow us to monitor oxygenation status.
b (Rationale Indwelling catheters along with a temperature of 101.5oF indicate the client may be developing septicemia and may require a transfer to the ICU. The client with GERD who is NPO is not at risk for septicemia. A ruptured appendix, not a nonruptured appendix, would place the client at risk for septicemia. The client with a history of MI and an elevated blood pressure requires close monitoring, but not for septicemia.)
The nurse is caring for several clients on a step down unit at a local hospital. Which client would require priority assessment for septicemia? a Client with a history of myocardial infarction with BP 130/90 b Client with an indwelling urinary catheter and a temperature of 101.5oF c Client with GERD who is NPO d Client with a nonruptured appendix with stable vital signs
a,b,d,e (Rationale Clients with the following portals of entry are at risk for infections that may lead to sepsis: clients with catheterizations, those undergoing respiratory therapies, and those with peptic ulcers, ruptured appendix, peritonitis, surgical wounds, IVs, decubitus ulcers, burns, and traumas. Female clients with STIs, who use tampons, or who have surgical abortions are at risk for septic shock. Other clients at risk for developing sepsis related to infections are those clients who are hospitalized, have debilitating chronic illnesses, have poor nutritional status, have had an invasive procedure or surgery, and those who are older adults or immunocompromised.)
The nurse is providing care to several clients on a medical-surgical unit. Which clients would require priority assessment for the development of septic shock?(Select all that apply.) a The client admitted with chronic renal failure b The client being treated for an STI c A client with latex allergies d The client with an indwelling urinary catheter e The client admitted for a nonhealing surgical wound
b,e (Expected lab findings for septic shock include decreasing levels of glucose and sodium, increased potassium levels;renal function declines as reduced perfusion and microclotting damage occurs and BUN, creatinine, urine specific gravity and osmolality increases.WBC count decreases as cells are destroyed and increased neutrophils and monocytes indicate acute bacterial infection. Septic shock causes a decrease in pH (indicating acidosis), a decrease in PaO2and total oxygen saturation, and an increase in PaCO2.)
Which diagnostic test results are expected for a client with septic shock? (Select all that apply.) a An increase in PaO b Increased neutrophil count c Decreased BUN and creatinine d Normal white blood cell count e Decreased glucose level
2 (ARDS is a complication associated with septic shock. ARDS causes respiratory failure and may lead to death even after the client has recovered from shock. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial airflow and involves chronic bronchitis, and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction)
Which finding is an indication of a complication of septic shock? 1. anaphylaxis 2. ARDS 3. COPD 4 mitral valve prolapse
b (Nursing diagnoses that are appropriate for a client with sepsis include: risk for shock, impaired gas exchange, risk for ineffective renal perfusion, ineffective peripheral tissue perfusion, and risk for imbalanced fluid volume.)
Which nursing diagnosis is appropriate for a client with sepsis? a Altered nutritional status b Ineffective peripheral tissue perfusion c Risk for body image disturbance d Risk for painful abdominal distention
4 (Maintaining asepsis of indwelling catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90%. In some populations, very young and elderly clients (those younger than 2 and older than 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining VS q4h on all clients and monitoring RBC counts for elevation do not pertain to septic shock prevention)
Which nursing intervention is most important in preventing septic shock? 1. Administering IV fluid replacement therapy as prescribed 2. obtaining VS q 4 h for all clients 3. monitoring RBC counts for elevation 4. maintaining asepsis of indwelling urinary catheters
b (When assessing a client with sepsis, the nurse monitors hemodynamic status with a central venous pressure (CVP) line or a pulmonary artery catheter. Normal CVP is 2-8 mmHg and is decreased with septic shock.)
Your client has been diagnosed with sepsis and is taken to the intensive care unit (ICU). Which assessment helps you monitor your client's hemodynamic status? a Assessing the client's capillary refill b Monitoring the CVP line c Palpating peripheral pulses d Observing vital signs
