SEPSIS QUESTIONS WITH DETAILED VERIFIED AND 100%
ACCURATE ANSWERS
ANS: B
Rationale: The 68-year-old woman has several risk factors. First she is
an older adult, and immune function decreases with age. The greatest
risk factor is that she has just had bowel surgery. Not only does major
surgery further reduce the immune response, the bowel cannot be
"sterilized" for surgery. Therefore the usual bacteria of the bowel have
the chance to escape the site and enter the bloodstream when the bowel
is disrupted. Correct Answers Which newly admitted client does the
nurse consider to be at highest risk for development of sepsis?
A. 75-year-old man with hypertension and early Alzheimer's disease
B. 68-year-old woman 2 days postoperative from bowel surgery
C. 80-year-old community-dwelling man with no other health problems
undergoing cataract surgery
D. 54-year-old woman with moderate asthma and severe degenerative
joint disease of the right knee
Suggested Responses:
1. What risk factors does this patient have for sepsis?
Risk factors include older age, diabetes mellitus, poor mobility and self-
care problems, a known urinary tract infection within the past 30 days,
and an open skin area on a lower extremity.
2. What manifestations does she have that are consistent with sepsis and
systemic inflammatory response syndrome (SIRS)?
,Manifestations include elevated temperature, a heart rate of more than
90 beats/min, a respiratory rate greater than 20 breaths/min, a blood
glucose level above 120 mg/dL, a recent known infection, decreasing
oxygen saturation, and confusion.
3. What assessment should you perform immediately?
Assess the color of her skin and mucous membranes, capillary refill, and
capnography. Obtain an order for a serum lactate level and a complete
blood count with differential. Also obtain an order to insert a Foley
catheter for accurate urine outp Correct Answers p. 825, Patient-
Centered Care; Evidence-Based Practice
The patient is an 82-year-old woman who has been a resident in an
extended-care facility for the past year because of poor mobility and
self-care problems. Today she is brought to the emergency department
because she does not recognize her son and does not know where she is.
She completed drug therapy for a urinary tract infection 1 week ago. Her
skin is thin, and she has many bruises. In addition, she has a healing
wound on her left shin, which her son tells you occurred 3 days ago
when she scraped the area trying to get out of bed alone. The skin
immediately surrounding the wound appears normal; however, about 3
inches to the right of the wound the skin is red, firm, and warm to the
touch. These are her vital signs: T, 100.8 F (38.2 C); P, 112 beats/min;
R, 24 breaths/min; BP, 118/80; SpO2, 92%. Oxygen at 3 L/min is
applied until the neurologist can evaluate her, and an IV with normal
saline is started at 100 mL/hr. Her son is concerned because she was
given her oral antidiabetic drug this morning (5 hours ago) but has not
eaten breakfast or lunch. When you check her blood glucose level, it is
131 mg/dL. When you assess her 15 minutes later, her oxygen saturation
is 90%.
1. What risk factors does this patient have for sepsis?
, 2. What manifestations does she have that are consistent with sepsis and
systemic inflammatory response syndrome (SIRS)?
3. What assessment should you perform immediately?
4. What would be the most likely source of infection?
5. Should you express concern about the possibility of sepsis and SIRS
to the emergency department intensivist? Why or why not?
ANS: A
Furosemide will lower the filling pressures and renal perfusion further
for the patient
with septic shock. The other orders are appropriate. Correct Answers 1.
A patient with septic shock has a urine output of 20 mL/hr for the past 3
hours. The pulse
rate is 120 and the central venous pressure and pulmonary artery wedge
pressure are low.
Which of these orders by the health care provider will the nurse
question?
a. Give furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 150 mL/hr.
c. Administer hydrocortisone (SoluCortef) 100 mg IV.
d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.
ANS: A
The elevated serum creatinine level indicates that the patient has renal
failure as well as
ACCURATE ANSWERS
ANS: B
Rationale: The 68-year-old woman has several risk factors. First she is
an older adult, and immune function decreases with age. The greatest
risk factor is that she has just had bowel surgery. Not only does major
surgery further reduce the immune response, the bowel cannot be
"sterilized" for surgery. Therefore the usual bacteria of the bowel have
the chance to escape the site and enter the bloodstream when the bowel
is disrupted. Correct Answers Which newly admitted client does the
nurse consider to be at highest risk for development of sepsis?
A. 75-year-old man with hypertension and early Alzheimer's disease
B. 68-year-old woman 2 days postoperative from bowel surgery
C. 80-year-old community-dwelling man with no other health problems
undergoing cataract surgery
D. 54-year-old woman with moderate asthma and severe degenerative
joint disease of the right knee
Suggested Responses:
1. What risk factors does this patient have for sepsis?
Risk factors include older age, diabetes mellitus, poor mobility and self-
care problems, a known urinary tract infection within the past 30 days,
and an open skin area on a lower extremity.
2. What manifestations does she have that are consistent with sepsis and
systemic inflammatory response syndrome (SIRS)?
,Manifestations include elevated temperature, a heart rate of more than
90 beats/min, a respiratory rate greater than 20 breaths/min, a blood
glucose level above 120 mg/dL, a recent known infection, decreasing
oxygen saturation, and confusion.
3. What assessment should you perform immediately?
Assess the color of her skin and mucous membranes, capillary refill, and
capnography. Obtain an order for a serum lactate level and a complete
blood count with differential. Also obtain an order to insert a Foley
catheter for accurate urine outp Correct Answers p. 825, Patient-
Centered Care; Evidence-Based Practice
The patient is an 82-year-old woman who has been a resident in an
extended-care facility for the past year because of poor mobility and
self-care problems. Today she is brought to the emergency department
because she does not recognize her son and does not know where she is.
She completed drug therapy for a urinary tract infection 1 week ago. Her
skin is thin, and she has many bruises. In addition, she has a healing
wound on her left shin, which her son tells you occurred 3 days ago
when she scraped the area trying to get out of bed alone. The skin
immediately surrounding the wound appears normal; however, about 3
inches to the right of the wound the skin is red, firm, and warm to the
touch. These are her vital signs: T, 100.8 F (38.2 C); P, 112 beats/min;
R, 24 breaths/min; BP, 118/80; SpO2, 92%. Oxygen at 3 L/min is
applied until the neurologist can evaluate her, and an IV with normal
saline is started at 100 mL/hr. Her son is concerned because she was
given her oral antidiabetic drug this morning (5 hours ago) but has not
eaten breakfast or lunch. When you check her blood glucose level, it is
131 mg/dL. When you assess her 15 minutes later, her oxygen saturation
is 90%.
1. What risk factors does this patient have for sepsis?
, 2. What manifestations does she have that are consistent with sepsis and
systemic inflammatory response syndrome (SIRS)?
3. What assessment should you perform immediately?
4. What would be the most likely source of infection?
5. Should you express concern about the possibility of sepsis and SIRS
to the emergency department intensivist? Why or why not?
ANS: A
Furosemide will lower the filling pressures and renal perfusion further
for the patient
with septic shock. The other orders are appropriate. Correct Answers 1.
A patient with septic shock has a urine output of 20 mL/hr for the past 3
hours. The pulse
rate is 120 and the central venous pressure and pulmonary artery wedge
pressure are low.
Which of these orders by the health care provider will the nurse
question?
a. Give furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 150 mL/hr.
c. Administer hydrocortisone (SoluCortef) 100 mg IV.
d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.
ANS: A
The elevated serum creatinine level indicates that the patient has renal
failure as well as
