SEPSIS NCLEX QUESTIONS WITH DETAILED VERIFIED
AND 100% ACCURATE ANSWERS
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) Correct Answers 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.
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 Correct 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.
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. Correct
Answers ANS: A
Furosemide will lower the filling pressures and renal perfusion further
for the patient
with septic shock. The other orders are appropriate.
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.
Correct Answers 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.
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). Correct Answers ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are
administered to increase
AND 100% ACCURATE ANSWERS
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) Correct Answers 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.
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 Correct 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.
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. Correct
Answers ANS: A
Furosemide will lower the filling pressures and renal perfusion further
for the patient
with septic shock. The other orders are appropriate.
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.
Correct Answers 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.
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). Correct Answers ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are
administered to increase
