Test Bank Shock, Sepsis, and Multiple Organ Dysfunction Syndrome all questions and

explained answers 2020/2021

MULTIPLE CHOICE

1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready

brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action?

a. Assess the blood pressure by Doppler.

b. Estimate the systolic pressure as 60 mm Hg.

c. Obtain an electronic blood pressure monitor.

d. Record the blood pressure as “not assessable.”

ANS: A

Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction.

If blood pressure is not audible, the approximate value can be assessed by palpation or

ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure

is 80 mm Hg. This action has the potential to delay further assessment of a compromised

patient in shock. Documenting a blood pressure as not assessable is not appropriate without

further attempts using different modalities.

DIF: Cognitive Level: Application REF: p. 258

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes,

nursing interventions, and rationales. TOP: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a

patient with severe sepsis. One hour later, which laboratory result requires immediate nursing

action?

a. Creatinine 1.0 mg/dL

b. Lactate 6 mmol/L

c. Potassium3.8 mEq/L

d. Sodium140 mEq/L

ANS: B

Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy

of resuscitation in shock, and as an outcome predictor. All other listed values are within

normal limits and do not require additional follow-up.

DIF: Cognitive Level: Application REF: p. 259 | Laboratory Alert

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

3. The nurse has been administering 0.9% normal saline intravenous fluids as part of early goaldirected therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of

fluid therapy, which physiological parameters would be most important for the nurse to

assess?

a. Breath sounds and capillary refill

b. Blood pressure and oral temperature

c. Oral temperature and capillary refill

 1 / 2

d. Right atrial pressure and urine output

ANS: D

Early goal-directed therapy includes administration of IV fluids to keep central venous

pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can

be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in

a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a

quick assessment of the patient’s overall cardiovascular status, but this assessment is not

reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of

oral temperature does not assess the effectiveness of fluid therapy in patients in shock.

Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in

shock. Capillary refill provides a quick assessment of the patient’s overall cardiovascular

status, but this assessment is not reliable in a patient who is hypothermic or has peripheral

circulatory problems.

DIF: Cognitive Level: Application REF: p. 282

OBJ: Describe management strategies for each classification of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

4. A patient is admitted to the critical care unit following coronary artery bypass surgery. Two

hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min;

blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac

output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best

interpretation by the nurse?

a. The assessed values are within normal limits.

b. The patient is at risk for developing cardiogenic shock.

c. The patient is at risk for developing fluid volume overload.

d. The patient is at risk for developing hypovolemic shock.

ANS: D

Vital signs and hemodynamic values assessed collectively include classic signs and symptoms

of hypovolemia. Both urine output and chest drainage values are high, contributing to the

hypovolemia. Assessed values are not within normal limits.

A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for

hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine

output.

DIF: Cognitive Level: Analysis REF: p. 270 | Table 11-5

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

5. A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a

heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46

mm Hg. The nurse anticipates administering which therapeutic intervention?

a. Human albumin infusion

b. Hypotonic saline solution

c. Lactated Ringer’s bolus

d. Packed red blood cells

ANS: C

Powered by qwivy(www.qwivy.org)

 2 / 2