Deck 54: Caring for the Patient With Inflammatory Response, Shock, and Severe Sepsis

Question 1

A patient who was stabbed in the abdomen has received fluid resuscitation of 2 liters over the last hour. Which finding would the nurse evaluate as indicating this intervention has been ineffective?

A) Patient complaints of abdominal pain
B) Patient's request to see a priest
C) Urine output of 45 mL for this hour
D) Heart rate 142 and regular

Answer 1

Heart rate 142 and regular

Question 2

The nurse is caring for a patient with MODS secondary to septic shock whose urine output was 10 mL for the last 2 hours. Temperature is 97 degrees, pulse is 124 and thready, and BP is 88/48. Which order is the current priority?

A) Place the patient on a warming blanket.
B) Administer isotonic fluids at 20 mL/kg/hr.
C) Draw blood for BUN and creatinine.
D) Place the patient in a kinetic bed.

Answer 2

Administer isotonic fluids at 20 mL/kg/hr.

Question 3

A patient admitted to the emergency department after a traumatic injury is becoming more and more lethargic and hard to arouse. Periods of apnea are increasing. To protect the patient's airway, the nurse should prepare to assist with which intervention?

A) Monitoring oxygen saturation
B) Endotracheal intubation
C) Assessment of breath sounds
D) Asking the patient if it is becoming difficult to breathe

Answer 3

Endotracheal intubation

Question 4

The nurse is reviewing the diagnostic tests for a patient with an infection. Which test result would the nurse attribute to this diagnosis?

A) Potassium 2.9 mEq/L
B) Hemoglobin 8.5 gm/dL/ Hematocrit 25.2%
C) Decreased activated protein C
D) WBCs 5,000 cells/cubic mm

Question 5

According to standard definitions, which patient would the nurse describe as being in septic shock?

A) A patient with community-acquired pneumonia who has developed respiratory failure
B) A patient who has burns over 40% of the body and is febrile
C) A patient with an infection whose blood pressure is 84/52 after 4 liters of saline were administered intravenously
D) A patient with a WBC count of 22,000 and fever

Question 6

A patient in shock is receiving norepinephrine by continuous infusion. For which outcome would the nurse monitor to evaluate the effectiveness of this medication?

A) Cardiac enzymes
B) Reduced apical heart rate
C) Reduction in bleeding
D) Blood pressure

Question 7

The critical care nurse is delivering a peer lecture on guidelines for the management of SIRS and severe sepsis. Which intervention would the nurse describe as improving outcomes in septic shock?

A) Use bicarbonate for pH of 7.30.
B) Keep mechanically ventilated patients flat in bed.
C) Maintain blood glucose lower than 150 mg/dL.
D) Initiate antibiotic therapy within 4 hours of diagnosis.

Question 8

The nurse plans to administer normal saline to a patient with systemic inflammatory response syndrome SIRS) and hypotension. At which rate would the nurse anticipate administering this fluid?

A) 20 mL/hr
B) 500 mL/hr
C) 100 mL/hr
D) 0.05 mL/kg/hr

Question 9

A patient has developed severe cardiogenic shock and is on a mechanical ventilator. The family asks why the patient's hands feel so cold. What is the nurse's best response?

A) "We keep the intensive care unit cool to reduce patients' metabolic rates."
B) "The patient has developed a fever and chills."
C) "This happens frequently to patients in shock states."
D) "Blood vessels constrict in shock, which takes the blood away from hands and feet."

Question 10

The nurse will plan which interventions to reduce metabolic demands in a patient with multiple organ dysfunction syndrome MODS)?

A) Provide skin care and positioning to prevent breakdown.
B) Use meticulous hand hygiene and aseptic technique for procedures.
C) Place the patient on a high-fat diet to increase energy.
D) Administer antipyretics for fever

Question 11

The nurse would be most alert for assessment findings of hypovolemic shock in which patient?

A) Patient who had a DVT after a surgical procedure 2 years ago
B) Patient 6 hours postmastectomy
C) Patient with coronary atherosclerosis who takes 81 mg of aspirin daily
D) Patient sustaining a transmural myocardial infarction 2 days ago

Question 12

The nurse is caring for a patient with septic shock and MODS. A family member tearfully tells the nurse, "The doctor said my mother's organs are shutting down. How did that happen?" What is the nurse's best response?

A) "The infection attacks and destroys each organ, causing it to fail."
B) "Fever damages the brain, which controls all organs."
C) "Deprivation of oxygen during shock causes organs to fail to function properly."
D) "The stress of illness has overwhelmed your loved one."

Question 13

Which patients would the nurse identify as being at increased risk for the development of hypovolemic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) A patient with systemic lupus erythematosus
B) A patient who had a myocardial infarction
C) A patient with cirrhosis, ascites, and anasarca
D) A patient who was the unrestrained front-seat passenger in a multivehicle car crash
E) Patient with ruptured abdominal aortic aneurysm

Question 14

The nurse would identify which patients as being at increased risk for development of sepsis and septic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) A patient admitted from a nursing home for treatment of a stage 4 pressure ulcer
B) A patient with a ruptured viscus who is vomiting bright red blood
C) A patient who takes methotrexate for rheumatoid arthritis
D) A patient who sustained blunt trauma to the spinal cord
E) A patient being treated for aplastic anemia

Question 15

A patient who takes a beta adrenergic blocker is at risk of developing shock after an accident. The nurse is aware that the patient's medication use may alter which assessment finding associated with shock?

A) Tachycardia
B) Declining mental status
C) Cyanosis
D) Tachypnea

Question 16

The nurse is caring for a patient with endocarditis who is receiving penicillin. The nurse should be particularly attentive to recognize early symptoms of which type of shock?

A) Hypovolemic
B) Cardiogenic
C) Septic
D) Anaphylactic

Question 17

An 80-year-old patient is being admitted from a nursing home for treatment of septic shock. Which assessment finding should the nurse investigate as the most likely source of the sepsis?

A) A red, flat rash in the perineal area
B) History of exposure to a daughter who is receiving chemotherapy
C) Report that several patients at the nursing home have scabies
D) An indwelling urinary catheter inserted 3 days ago by nursing home personnel

Question 18

The nurse is caring for a patient with papillary muscle rupture. The nurse would be most alert to the development of which type of shock?

A) Septic
B) Cardiogenic
C) Anaphylactic
D) Neurogenic

Question 19

A patient developed septic shock related to cancer chemotherapy. This morning the nurse assessed a change in the patient's mental status. The nurse's primary concern would focus on which possible etiology for this change?

A) Anxiety about and fear of death
B) Metastasis of underlying cancer
C) A result of chemotherapy
D) Decreased tissue oxygenation

Question 20

The nurse anticipates assisting with which therapy to achieve improved outcomes for a patient who is in septic shock?

A) Vasopressin instead of dopamine for hypotension
B) Early use of neuromuscular blocking agents
C) Limiting fluids to 3 liters per day
D) Mechanical ventilation with a tidal volume of 4 to 6 ml/kg

Question 21

A patient diagnosed with spinal shock has been receiving an intravenous steroid for 8 days. Which findings would be the nurse's priority to discuss with the prescriber? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The patient has developed a fever.
B) The patient's potassium has dropped from 4.3 to 3.8 mEq/L.
C) The patient's blood glucose was 230 mg/dL this morning.
D) The patient's stools are dark and sticky.
E) The patient's surgical incision is not healing.

Question 22

Which statements by the paramedic who brought a patient to the emergency department would indicate correct field treatment of a patient suspected of being in shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) "An endotracheal tube was inserted prior to transport."
B) "Secondary assessment took place during transport."
C) "The IV was started while we were at the scene."
D) "My partner applied direct pressure to the bleeding wound as we moved the patient to the ambulance."
E) "Blood was drawn for blood cultures before we left the scene."

Question 23

A patient was admitted directly from a physician's office with suspected sepsis. The nurse contacts the pharmacy with the medication orders immediately because the antibiotic must be administered within _______ minutes of admission.

Question 24

A patient with sepsis has been ordered IV dopamine. Which assessment findings should the nurse discuss with the prescriber prior to administering this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The patient's heart rate has dropped from 100 bpm to 80 bpm.
B) The patient's urinary output is 20 mL in the last hour.
C) Epinephrine has not yet been given.
D) The patient does not yet have a central line.
E) The patient's mean arterial pressure is 58 mmHg.

Question 25

A patient diagnosed with MODS is being mechanically intubated and is unable to eat. Enteral feedings are prescribed along with a proton-pump inhibitor. Which particular intervention is indicated related to this medication?

A) Monitor the serum sodium level.
B) Monitor the uric acid level.
C) Monitor for the development of ventilator-associated pneumonia.
D) Monitor for the development of urinary tract infection.

Question 26

A patient is brought to the emergency department with injuries sustained in a gang fight. The patient's blood pressure is 80/50 mmHg with a pulse of 120 and thready. The nurse will prepare the patient for which test to provide the fastest diagnostic information?

A) Sonogram
B) Complete blood count
C) Urinalysis
D) Serum electrolyte levels

Question 27

A patient has MODS secondary to severe sepsis. The nurse would prioritize interventions to address which finding in this patient?

A) WBC count of 28,000 cell/cubic mm
B) Blood glucose of 245 mg/dL
C) pO₂ of 54 mmHg
D) Serum lactate level of 2.1 mmol/L

Question 28

A patient diagnosed with shock is prescribed dobutamine Dobutrex). The nurse would evaluate which finding as indicating the medication has had the desired effect?

A) Increased cardiac output
B) Decreased temperature
C) Decreased respiratory rate
D) Decreased blood pressure

Question 29

The nurse is concerned that a 10-year-old patient injured in a motor vehicle accident may be developing septic shock. Which assessment findings would support this concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The heart rate is 120 bpm sustained.
B) The patient has thready peripheral pulses.
C) The patient is crying.
D) Capillary refill is 2 seconds.
E) The patient has diarrhea.

Question 30

A 60-year-old woman with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. The nurse realizes that because there is insufficient time for type and crossmatch, the patient could receive which types of blood? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) O-positive
B) AB-positive
C) A-negative
D) O-negative
E) A-positive

Question 31

The nurse would be most alert for assessment findings of obstructive shock in which patients? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) A patient who has tumor mass in the vena cava
B) A patient who sustained a gunshot wound to the abdomen
C) A patient who suffered a severe cardiac contusion
D) The patient who sustained several fractured ribs in a fall
E) A patient who has pneumonia caused by a multiple-drug-resistant organism

Question 32

A patient is suspected of having severe sepsis. What should the nurse anticipate concerning antibiotic therapy for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Several antibiotics will be started on the same day.
B) The antibiotic prescribed will be one commonly used in the hospital.
C) The initial antibiotic will be broad-spectrum.
D) The antibiotic therapy will be reevaluated in 2 or 3 days and is likely to be changed.
E) Before choosing an antibiotic, the prescriber will ask questions about where the patient lives and has traveled.

Question 33

A patient was diagnosed with sepsis 5 hours ago. To meet the criteria of the Sepsis Resuscitation Bundle, the nurse and health care team must complete the bundle within ______ hours).

Question 34

The emergency department nurse would expect which patients to arrive by ambulance with pneumatic antishock garments PASGs) in place? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) A patient with part of a fence post impaled in the abdomen
B) A patient whose intestines have eviscerated through an infected surgical wound
C) A patient whose blood pressure is 84/58 mmHg and who has suspected pelvic fractures
D) A patient suspected of intraperitoneal hemorrhage with systolic blood pressure of 58 mmHg
E) A patient who has a compound fracture of the left lower leg.

Question 35

A 20-year-old male was seriously wounded in a shooting incident and is not expected to survive the resulting hypovolemic shock. Which nursing statements to the family are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) "The rules allow only two visitors for 5 minutes."
B) "Your son's color is very gray."
C) "Your son will not be able to talk to you, but he will know you are there."
D) "Your son has a big bandage around his head and his face is swollen and bruised."
E) "We have given your son pain medication for his wounds."