NUR250 FINAL GROUP 1 - SEPSIS - NCLEX QUESTIONS
WITH DETAILED VERIFIED AND 100% ACCURATE
ANSWERS
1. Septic shock causes system wide vasodilation which leads to an
increase in systemic vascular resistance. In addition, septic shock causes
increased capillary permeability and clot formation in the
microcirculation throughout the body.
TRUE or FALSE? Correct Answers FALSE
RATIONALE: This statement is incorrect because there is a
DECREASE (not increased) systemic vascular resistance in septic shock
due to vasodilation. In septic shock, vasodilation is system wide. In
addition, septic shock causes increased capillary permeability and
thrombi formation in the microcirculation throughout the body. The
vasodilation, increased capillary permeability, and clot formation in the
microcirculation all leads to a decrease in tissue perfusion. This causes
organ and tissue dysfunction, hence septic shock.
2. A patient is diagnosed with septic shock. As the nurse you know this
is a __________ form of shock. In addition, you're aware that
__________ and _________ are also this form of shock.
A. obstructive; hypovolemic and anaphylactic
B. distributive; anaphylactic and neurogenic
C. obstructive; cardiogenic and neurogenic
,D. distributive; anaphylactic and cardiogenic Correct Answers The
correct answer is B.
RATIONALE: Septic shock is a form of distributive shock. This means
there is an issue with the distribution of blood flow in the small blood
vessels of the body. This results in a diminished supply of blood to the
body's tissues and organs. Anaphylactic and neurogenic shock are also a
type of distributive form of shock. Septic shock isn't occurring due to an
issue with cardiac output, which occurs in hypovolemic and cardiogenic
shock.
3. Your patient, who is post-op from a gastrointestinal surgery, is
presenting with a temperature of 103.6 'F, heart rate 120, blood pressure
72/42, increased white blood cell count, and respirations of 21. An IV
fluid bolus is ordered STAT. Which findings below indicate that the
patient is progressing to septic shock? Select all that apply:
A. Blood pressure of 70/34 after the fluid bolus
B. Serum lactate less than 2 mmol/L
C. Patient needs Norepinephrine to maintain a mean arterial pressure
(MAP) greater than 65 mmHg despite fluid replacement
D. Central venous pressure (CVP) of 18 Correct Answers The correct
answers are A and C.
RATIONALE: To know if the patient is progressing to septic shock, you
need to think about the hallmark findings associated with this condition.
Septic shock is characterized by major persistent hypotension (<90 SBP)
that doesn't respond to IV fluids (refractory hypotension), and the patient
, needs vasopressors (ex: Norepinephrine) to maintain a mean arterial
pressure greater than 65 and their serum lactate is greater than 2
mmol/L. A serum lactate greater than 2 indicates the cell's tissue/organs
are not functioning properly due to low oxygen; hence tissue perfusion is
poor due to the low blood pressure and mean arterial pressure.
4. You're providing care to four patients. Select all the patients who are
at risk for developing sepsis (SELECT ALL THAT APPLY):
A. A 35-year-old female who is hospitalized with renal insufficiency and
has a Foley catheter and central line in place.
B. A 55-year-old male who is a recent kidney transplant recipient.
C. A 78-year-old female with diabetes mellitus who is recovering from
colon surgery.
D. A 65-year-old male recovering from right lobectomy for treatment of
lung cancer. Correct Answers All the answers are correct.
RATIONALE: All the patients have risk factors for developing sepsis.
Remember the mnemonic: Septic.....Suppressed immune system
(AIDS/HIV, immunosuppressive therapy, steroids, chemo, pregnancy,
malnutrition)....Extreme age (infants and elderly)...Post-op
(surgical/invasive procedures)....Transplant recipients.....Indwelling
devices (Foley catheter, central lines, trachs).....Chronic diseases
(diabetes, hepatitis, alcoholism, renal insufficiency)
5. A patient with a severe infection has developed septic shock. The
patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen
saturation 96% on high-flow oxygen, and temperature 103.6 'F. The
WITH DETAILED VERIFIED AND 100% ACCURATE
ANSWERS
1. Septic shock causes system wide vasodilation which leads to an
increase in systemic vascular resistance. In addition, septic shock causes
increased capillary permeability and clot formation in the
microcirculation throughout the body.
TRUE or FALSE? Correct Answers FALSE
RATIONALE: This statement is incorrect because there is a
DECREASE (not increased) systemic vascular resistance in septic shock
due to vasodilation. In septic shock, vasodilation is system wide. In
addition, septic shock causes increased capillary permeability and
thrombi formation in the microcirculation throughout the body. The
vasodilation, increased capillary permeability, and clot formation in the
microcirculation all leads to a decrease in tissue perfusion. This causes
organ and tissue dysfunction, hence septic shock.
2. A patient is diagnosed with septic shock. As the nurse you know this
is a __________ form of shock. In addition, you're aware that
__________ and _________ are also this form of shock.
A. obstructive; hypovolemic and anaphylactic
B. distributive; anaphylactic and neurogenic
C. obstructive; cardiogenic and neurogenic
,D. distributive; anaphylactic and cardiogenic Correct Answers The
correct answer is B.
RATIONALE: Septic shock is a form of distributive shock. This means
there is an issue with the distribution of blood flow in the small blood
vessels of the body. This results in a diminished supply of blood to the
body's tissues and organs. Anaphylactic and neurogenic shock are also a
type of distributive form of shock. Septic shock isn't occurring due to an
issue with cardiac output, which occurs in hypovolemic and cardiogenic
shock.
3. Your patient, who is post-op from a gastrointestinal surgery, is
presenting with a temperature of 103.6 'F, heart rate 120, blood pressure
72/42, increased white blood cell count, and respirations of 21. An IV
fluid bolus is ordered STAT. Which findings below indicate that the
patient is progressing to septic shock? Select all that apply:
A. Blood pressure of 70/34 after the fluid bolus
B. Serum lactate less than 2 mmol/L
C. Patient needs Norepinephrine to maintain a mean arterial pressure
(MAP) greater than 65 mmHg despite fluid replacement
D. Central venous pressure (CVP) of 18 Correct Answers The correct
answers are A and C.
RATIONALE: To know if the patient is progressing to septic shock, you
need to think about the hallmark findings associated with this condition.
Septic shock is characterized by major persistent hypotension (<90 SBP)
that doesn't respond to IV fluids (refractory hypotension), and the patient
, needs vasopressors (ex: Norepinephrine) to maintain a mean arterial
pressure greater than 65 and their serum lactate is greater than 2
mmol/L. A serum lactate greater than 2 indicates the cell's tissue/organs
are not functioning properly due to low oxygen; hence tissue perfusion is
poor due to the low blood pressure and mean arterial pressure.
4. You're providing care to four patients. Select all the patients who are
at risk for developing sepsis (SELECT ALL THAT APPLY):
A. A 35-year-old female who is hospitalized with renal insufficiency and
has a Foley catheter and central line in place.
B. A 55-year-old male who is a recent kidney transplant recipient.
C. A 78-year-old female with diabetes mellitus who is recovering from
colon surgery.
D. A 65-year-old male recovering from right lobectomy for treatment of
lung cancer. Correct Answers All the answers are correct.
RATIONALE: All the patients have risk factors for developing sepsis.
Remember the mnemonic: Septic.....Suppressed immune system
(AIDS/HIV, immunosuppressive therapy, steroids, chemo, pregnancy,
malnutrition)....Extreme age (infants and elderly)...Post-op
(surgical/invasive procedures)....Transplant recipients.....Indwelling
devices (Foley catheter, central lines, trachs).....Chronic diseases
(diabetes, hepatitis, alcoholism, renal insufficiency)
5. A patient with a severe infection has developed septic shock. The
patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen
saturation 96% on high-flow oxygen, and temperature 103.6 'F. The
