Sepsis NCLEX | UPDATED Questions with 100% Verified
Answers
Northern Virginia Community College • NSG 252
Q1: Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is
effective? A. Urine output increase from 5 mL/hr to 25 mL/hr B. Pulse pressure decrease from 35 mm Hg to
28 mm Hg C. Respiratory rate increase from 22 breaths/min to 26 breaths/min D. Core body temperature
increase from 98.2 F (36.8 C) to 98.8 F (37.1 C)
A: ANS: A
Rationale: During shock, the kidneys and baroreceptors sense an ongoing decrease in
MAP and trigger the release of renin, antidiuretic hormone (ADH), aldosterone,
epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to
changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output.
ADH increases water reabsorption in the kidney, further reducing urine output. These
actions compensate for shock by attempting to prevent further fluid loss. This response is
so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If
the therapy is not effective, urine output does not increase.
Q2: Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A.
75yearold man with hypertension and early Alzheimer's disease B. 68yearold woman 2 days postoperative
from bowel surgery C. 80yearold communitydwelling man with no other health problems undergoing
cataract surgery D. 54yearold woman with moderate asthma and severe degenerative joint disease of the
right knee
A: ANS: B
Rationale: The 68yearold 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.
Q3: 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.
A: ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the patient
with septic shock. The other orders are appropriate.
, Q4: 2. A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse
64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions
prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of
bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg. d. Administer
dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
A: ANS: A
The patient's elevated pulmonary artery wedge pressure indicates volume excess. A
normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate
for the patient.
Q5: 5. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic
shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration
of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium
nitroprusside (Nipride).
A: ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase
the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin
would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha
may decrease inappropriate inflammation and help prevent systemic inflammatory
response syndrome, but it will not directly improve blood pressure. Nitroprusside is an
arterial vasodilator and would further decrease SVR.
Q6: 8. The emergency department (ED) receives notification that a patient who has just been in an
automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation
for the patient's arrival, the nurse will obtain a. 500 mL of 5% albumin. b. lactated Ringer's solution. c. two
14gauge IV catheters. d. dopamine (Intropin) infusion.
A: ANS: C
A patient with multiple trauma may require fluid resuscitation to prevent or treat
hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to
administer normal saline. Lactated Ringer's solution should be used cautiously and will
not be ordered until the patient has been assessed for possible liver abnormalities.
Although colloids may sometimes be used for volume expansion, crystalloids should be
used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the
initial therapy for hypovolemic shock.
Q7: 9. Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic
shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last
hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.
A: ANS: B
Assessment of end organ perfusion, such as an adequate urine output, is the best
indicator
that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are
useful in determining the effects of fluid administration, but they are not as useful as data
indicating good organ perfusion.
Answers
Northern Virginia Community College • NSG 252
Q1: Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is
effective? A. Urine output increase from 5 mL/hr to 25 mL/hr B. Pulse pressure decrease from 35 mm Hg to
28 mm Hg C. Respiratory rate increase from 22 breaths/min to 26 breaths/min D. Core body temperature
increase from 98.2 F (36.8 C) to 98.8 F (37.1 C)
A: ANS: A
Rationale: During shock, the kidneys and baroreceptors sense an ongoing decrease in
MAP and trigger the release of renin, antidiuretic hormone (ADH), aldosterone,
epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to
changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output.
ADH increases water reabsorption in the kidney, further reducing urine output. These
actions compensate for shock by attempting to prevent further fluid loss. This response is
so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If
the therapy is not effective, urine output does not increase.
Q2: Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A.
75yearold man with hypertension and early Alzheimer's disease B. 68yearold woman 2 days postoperative
from bowel surgery C. 80yearold communitydwelling man with no other health problems undergoing
cataract surgery D. 54yearold woman with moderate asthma and severe degenerative joint disease of the
right knee
A: ANS: B
Rationale: The 68yearold 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.
Q3: 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.
A: ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the patient
with septic shock. The other orders are appropriate.
, Q4: 2. A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse
64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions
prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of
bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg. d. Administer
dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
A: ANS: A
The patient's elevated pulmonary artery wedge pressure indicates volume excess. A
normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate
for the patient.
Q5: 5. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic
shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration
of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium
nitroprusside (Nipride).
A: ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase
the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin
would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha
may decrease inappropriate inflammation and help prevent systemic inflammatory
response syndrome, but it will not directly improve blood pressure. Nitroprusside is an
arterial vasodilator and would further decrease SVR.
Q6: 8. The emergency department (ED) receives notification that a patient who has just been in an
automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation
for the patient's arrival, the nurse will obtain a. 500 mL of 5% albumin. b. lactated Ringer's solution. c. two
14gauge IV catheters. d. dopamine (Intropin) infusion.
A: ANS: C
A patient with multiple trauma may require fluid resuscitation to prevent or treat
hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to
administer normal saline. Lactated Ringer's solution should be used cautiously and will
not be ordered until the patient has been assessed for possible liver abnormalities.
Although colloids may sometimes be used for volume expansion, crystalloids should be
used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the
initial therapy for hypovolemic shock.
Q7: 9. Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic
shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last
hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.
A: ANS: B
Assessment of end organ perfusion, such as an adequate urine output, is the best
indicator
that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are
useful in determining the effects of fluid administration, but they are not as useful as data
indicating good organ perfusion.
