Sepsis Pearson NCLEX Questions
Which client should the nurse consider is at risk of sepsis? (Select all that apply.)
Answer: A client with a peptic ulcer, a client with an IV, a client with a surgical wound, a client with an STI Rationale: Portals of entry for infection may include the following systems: urinary, respiratory, gastrointestinal, integumentary, and female reproductive. Conditions 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 sepsis. Next Question
The nurse is assessing a client for septic shock. Which assessment finding supports this diagnosis?
Answer: CVP of 1 mmHg Rationale: When assessing a client with sepsis, the nurse monitors the client's hemodynamic status with a CVP intravenous line or pulmonary artery catheter. Normal CVP is 2dash-8 mmHg and is decreased with septic shock. The other vital signs are within normal limits.
The parents of a child undergoing diagnostic tests for an unexplained ongoing fever ask the pediatric nurse, "What does this word procalcitonin refer to?" Which detail can the nurse give them? (Select all that apply.)
Answer: its a marker of sepsis, its a mediator in lung and systemic infections, its a precursor of a hormone Rationale: Procalcitonin is the precursor of the hormone calcitonin, a marker of sepsis, and a mediator in lung and systemic infections. Procalcitonin has nothing to do with calcium or ultrasound exams.
Which outcome validates successful treatment of sepsis? (Select all that apply.)
Answer: o2 sats greater than 92%, average body temp of 98.5, MAP of 90mmHg Rationale: Treatment of sepsis not only includes treating the infection, but also managing symptoms. The client who has undergone successful treatment of sepsis would maintain a normal mean arterial pressure of 90 mmHg, oxygen saturation greater than 90%, and a normal body temperature. These findings indicate good tissue perfusion. Pale, cool, moist skin indicates poor thermoregulation. Urine output should be greater than 30 mL/hr, or 720 mL/day.
The nurse is caring for several hospitalized clients. Which client requires priority assessment for sepsis?
Answer: A client with a urinary catheter and a temperature of 101.5degrees°F (38.6degrees°C) Rationale: Indwelling catheters along with a temperature of 101.5°F (38.6°C) indicate that the client may be developing septicemia. 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 of septicemia. The client with a history of MI and an elevated blood pressure requires close monitoring but not for septicemia. Next Question
The nurse is assessing an acutely ill client diagnosed with septic shock. The nurse finds the client has developed purpura. Which condition should the nurse suspect that the client has developed?
Answer: DIC Rationale: DIC is characterized by simultaneous bleeding and clotting throughout the vasculature. Sepsis injures blood cells, causing platelet aggregation and decreased bloodflow. As a result, blood clots form throughout the microcirculation. The clotting slows circulation further while stimulating excess fibrinolysis. As the body's stores of clotting factorsare depleted, generalized bleeding begins. Purpura or spider angiomas are often seen on the client's skin. Influenza is a cause of sepsis. Renal failure is evidenced by decreased urinary output. Respiratory failure is manifested by tachypnea and dyspnea as well as arterial blood gas changes. Next Question
Which collaborative intervention should the nurse implement to alleviate the worsening of hypotension in the client with sepsis?
Answer: IV fluids Rationale: IV fluids will help to raise the blood pressure in a client with sepsis. Oxygen helps with aciddash-base balance and breathing. Ventilation provides breathing support. Antibiotics eradicate the causative bacteria.
The nurse is caring for a client admitted in the final stage of septic shock. Which syndrome does the nurse suspect the client has?
Answer: Multiple organ dysfunction syndrome (MODS) Rationale: 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 MODS, and ultimately death. TSS is an especially virulent form of septic shock and occurs most frequently in menstruating women who use tampons improperly. SIRS is a precursor to sepsis and can occur as a complication of virtually any infection of any body tissue. SIRS refers to a persistently low mean arterial blood pressure that results from overwhelming infection despite adequate fluid resuscitation. Next Question
The nurse is caring for a client with infection. Which condition should the nurse consider as a precursor to septic shock?
Answer: SIRS Rationale: SIRS, which is a precursor to sepsis, can occur as a complication of virtually any infection of any body tissue. In infection-related SIRS, the infection triggers a systemic inflammatory response that leads to a series of adverse events, including vasodilation, increased capillary permeability, and hypercoagulability. These lead to DIC, DVT, MODS, and ultimately death. Next Question
Which client requires priority assessment for the development of septic shock? (Select all that apply.)
Answer: a client with a nonhealing surgical wound, a client with chronic renal failure, a client with an indwelling urinary catheter, a client with pneumonia Rationale: Clients with the following portals of entry are at risk of infections that may lead to sepsis: those with catheterizations; those undergoing respiratory therapies; and those with peptic ulcers, ruptured appendix, peritonitis, surgical wounds, intravenous lines, decubitus ulcers, burns, and traumas. Clients with pneumonia are at higher risk of sepsis. Other clients at risk of developing sepsis related to infections are those who are hospitalized, have debilitating chronic illnesses, have poor nutritional status, have had an invasive procedure or surgery, and are older adults or immunocompromised.
The nurse caring for a client diagnosed with urosepsis finds spider angiomas of the extremities and cool fingertips. The healthcare provider suspects disseminated intravascular coagulation (DIC). Which collaborative intervention should the nurse implement?
Answer: administer fresh frozen plasma Rationale: A client with DIC is bleeding and clotting at the same time. Therefore, to control the bleeding, the healthcare provider would prescribe fresh frozen plasma, which contains clotting factors. Insulin is used to manage blood glucose levels in clients with diabetes. The client would receive IV fluids at a higher rate to compensate for fluid shifts. Total parenteral nutrition is used to treat malnutrition, not DIC. Next Question
A client is brought to the emergency department with infection. Which diagnostic test should the nurse anticipate the healthcare provider ordering to help determine risk for shock? (Select all that apply.)
Answer: gastric tonometry, MRI, CT Rationale: Gastric tonometry and sublingual partial pressure of carbon dioxide, arterial (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. Electromyography measures electrical activity in the muscles, and a cardiac catheterization visualizes the coronary arteries.
A client is diagnosed with septic shock. Which collaborative therapy should the nurse consider to be the priority?
Answer: give IV fluids Rationale: Fluid replacement is the priority intervention to help improve tissue perfusion. The client will also be immediately placed on oxygen to treat hypoxia. These interventions will be followed by administration of a broad-spectrum antibiotic. When fluid replacement alone is not sufficient to reverse shock, vasoactive drugs (drugs causing vasoconstriction or vasodilation) and inotropic drugs (drugs improving cardiac contractility) may be administered. When used to treat shock, these drugs increase venous return through vasoconstriction of peripheral vessels; they also improve the pumping ability of the heart by facilitating myocardial contractility and dilating coronary arteries to increase perfusion of the myocardium.
Which clinical manifestation should the nurse recognize as an indicator of early septic shock? (Select all that apply.)
Answer: hypotension, warm, flushed skin, weakness Rationale: Early, or warm, signs of septic shock include weakness, hypotension, and warmed, flushed skin. The nurse should be cognizant of these signs in order to prevent worsening of the client's condition. Oliguria and changes in mental status are signs of late, or cold, septic shock. Next Question
Which diagnostic test result would the nurse expect to find for a client with septic shock? (Select all that apply.)
Answer: increased neutrophils, decreased pH Rationale: Septic shock causes a decrease in pH (indicating acidosis), a decrease in PaO2 and total oxygen saturation, and an increase in PaCO2. WBC count decreases as cells are destroyed, and increased neutrophils and monocytes indicate acute bacterial infection. Renal function declines as reduced perfusion and microclotting damage the small renal arterioles. As perfusion of the kidneys is decreased and renal function is reduced, the BUN and creatinine levels increase, as do urine specific gravity and osmolality.
The nurse educator is providing an in-service about interventions that increase a client's risk for sepsis. Which information should the educator include?
Answer: invasive procedures Rationale: Invasive procedures such as catheterizations and surgeries can place a client at a higher risk of developing sepsis. Physical therapy, oral medications, and dietary restrictions are part of the treatment plan and help with healing. Next Question
The nurse should advise older adults to participate in which activity to help decrease the risk of developing sepsis?
Answer: obtaining annual flu vaccine Rationale: Older adults should obtain the annual influenza and pneumococcal vaccines as recommended to prevent the flu and pneumonia. These infections can lead to the development of sepsis. Walking and exercising daily, maintaining a low-cholesterol diet, and taking medications as prescribed lead to a healthy overall lifestyle but do not decrease the risk for sepsis.
The nurse is caring for a client diagnosed with septic shock. Which neurologic assessment finding requires immediate nursing intervention? (Select all that apply.)
Answer: restlessness, lethargy, disorientation Rationale: Altered level of consciousness is a result of cerebral hypoxia and the effects of acidosis on brain cells. 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. Acidosis does occur but is not a neurologic finding. The client in septic shock will have hyperthermia, not hypothermia.
Which finding should the nurse expect while assessing a client with sepsis? (Select all that apply.)
Answer: tachypnea, leukocytosis, confusion Rationale: Clinical manifestations of sepsis include mental status changes such as confusion, tachypnea, and either leukocytosis or leukopenia. The client will have hypotension as fluid leaves the intravascular space. The client will experience tachycardia, not bradycardia. Next Question
The nurse is teaching a group of teenage girls about toxic shock syndrome (TSS). Which action places this demographic group at higher risk of this disorder?
Answer: tampon usage Rationale: The use of tampons can cause microscopic abrasions to the vaginal area. This allows bacteria to enter the bloodstream, causing TSS. Smoking causes lung cancer. Unprotected sex can cause pregnancy and sexually transmitted infections. Underage drinking can lead to drunk driving and other health problems. Next Question
