SEPSIS SEPTIC SHOCK UNFOLDING
REASONING EXAM PREP QUESTIONS AND
ANSWERS FULL SOLUTION
●● A client experiencing vomiting and diarrhea for 2 days has a blood
pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate
of 28 breaths/minute. The nurse places the client in which position?
Answer: Modified Trendelenburg
The client is experiencing hypovolemic shock as a result of prolonged
vomiting and diarrhea. The modified Trendelenburg position is
recommended for hypovolemic shock because it promotes the return of
venous blood. The other positions may make breathing difficult and may
not increase blood pressure or cardiac output.
●● A client experiences an acute myocardial infarction. Current blood
pressure is 90/58, pulse is 118 beats/minute, and respirations are 30
breaths/minute. The nurse intervenes first by administering the following
prescribed treatment:
Answer: Oxygen at 2 L/min by nasal cannula
In the early stages of cardiogenic shock, the nurse first administers
supplemental oxygen to achieve an oxygen saturation exceeding 90%.
The nurse may then administer morphine to relieve chest pain and/or to
reduce the workload of the heart and decrease client anxiety. Intravenous
,fluids are given carefully to prevent fluid overload. Vasoactive
medications, such as dopamine, are then administered to restore and
maintain cardiac output.
●● A client is experiencing septic shock and infrequent bowel sounds.
To ensure adequate nutrition, the nurse administers
Answer: A continuous infusion of total parenteral nutrition
Nutritional supplementation is initiated within 24 hours of the start of
septic shock. If the client has reduced peristalsis, then parenteral
feedings will be required. Full liquid diet and enteral nutrition require
the oral route and would be contraindicated if the client is experiencing
decreased peristalsis. Increasing the rate of crystalloids does not provide
adequate nutrition.
●● The nursing student is preparing to care for an ICU client with shock.
The instructor asks the student to name the different categories of shock.
Which of the following is a category of shock?
Answer: Distributive
The four main categories of shock are hypovolemic, circulatory
(distributive), obstructive, and cardiogenic, depending on the cause. This
makes options A, C, and D incorrect.
●● Which vasodilator medication is used in the treatment of shock?
,Answer: Nitroglycerin
Nitroglycerin is a vasodilator used to reduce preload and afterload and
reduce oxygen demand of the heart. Dopamine and dobutamine are
sympathomimetic and are used to improve contractility, increase stroke
volume, and increase cardiac output. Norepinephrine is a vasoconstrictor
used to increase blood pressure by vasoconstriction.
●● The nurse is caring for a client newly diagnosed with sepsis. The
client has a serum lactate concentration of 6 mmol/L and fluid
resuscitation has been initiated. Which value indicates that the client has
received adequate fluid resuscitation?
Answer: Mean arterial pressure of 70 mm Hg
The nurse administers fluids to achieve a target central venous pressure
of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of
0.5 mL/kg/hr, and an ScvO2 of 70%.
●● What can the nurse include in the plan of care to ensure early
intervention along the continuum of shock to improve the client's
prognosis? Select all that apply.
Answer: 1. Assess the client who is at risk for shock.
2. Administer intravenous fluids.
3. Monitor for changes in vital signs.
, Early intervention along the continuum of shock is the key to improving
the client's prognosis. The nurse must systematically assess the client at
risk for shock, recognizing subtle clinical signs of the compensatory
stage before the client's BP drops. Early interventions include identifying
the cause of shock, administering intravenous (IV) fluids and oxygen,
and obtaining necessary laboratory tests to rule out and treat metabolic
imbalances or infection. In assessing tissue perfusion, the nurse observes
for changes in level of consciousness, vital signs (including pulse
pressure), urinary output, skin, and laboratory values (e.g., base deficit
and lactic acid levels). Administering vasoconstrictive medications or
prophylactic packed red blood cells is not necessary as an early
intervention.
●● The nurse is using continuous central venous oximetry (ScvO2) to
monitor the blood oxygen saturation of a patient in shock. What value
would the nurse document as normal for the patient?
Answer: 70%
Continuous central venous oximetry (ScvO2) monitoring may be used to
evaluate mixed venous blood oxygen saturation and severity of tissue
hypoperfusion states. A central catheter is introduced into the superior
vena cava (SVC), and a sensor on the catheter measures the oxygen
saturation of the blood in the SVC as blood returns to the heart and
pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.
●● A patient in shock would exhibit which one of the following clinical
findings?
REASONING EXAM PREP QUESTIONS AND
ANSWERS FULL SOLUTION
●● A client experiencing vomiting and diarrhea for 2 days has a blood
pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate
of 28 breaths/minute. The nurse places the client in which position?
Answer: Modified Trendelenburg
The client is experiencing hypovolemic shock as a result of prolonged
vomiting and diarrhea. The modified Trendelenburg position is
recommended for hypovolemic shock because it promotes the return of
venous blood. The other positions may make breathing difficult and may
not increase blood pressure or cardiac output.
●● A client experiences an acute myocardial infarction. Current blood
pressure is 90/58, pulse is 118 beats/minute, and respirations are 30
breaths/minute. The nurse intervenes first by administering the following
prescribed treatment:
Answer: Oxygen at 2 L/min by nasal cannula
In the early stages of cardiogenic shock, the nurse first administers
supplemental oxygen to achieve an oxygen saturation exceeding 90%.
The nurse may then administer morphine to relieve chest pain and/or to
reduce the workload of the heart and decrease client anxiety. Intravenous
,fluids are given carefully to prevent fluid overload. Vasoactive
medications, such as dopamine, are then administered to restore and
maintain cardiac output.
●● A client is experiencing septic shock and infrequent bowel sounds.
To ensure adequate nutrition, the nurse administers
Answer: A continuous infusion of total parenteral nutrition
Nutritional supplementation is initiated within 24 hours of the start of
septic shock. If the client has reduced peristalsis, then parenteral
feedings will be required. Full liquid diet and enteral nutrition require
the oral route and would be contraindicated if the client is experiencing
decreased peristalsis. Increasing the rate of crystalloids does not provide
adequate nutrition.
●● The nursing student is preparing to care for an ICU client with shock.
The instructor asks the student to name the different categories of shock.
Which of the following is a category of shock?
Answer: Distributive
The four main categories of shock are hypovolemic, circulatory
(distributive), obstructive, and cardiogenic, depending on the cause. This
makes options A, C, and D incorrect.
●● Which vasodilator medication is used in the treatment of shock?
,Answer: Nitroglycerin
Nitroglycerin is a vasodilator used to reduce preload and afterload and
reduce oxygen demand of the heart. Dopamine and dobutamine are
sympathomimetic and are used to improve contractility, increase stroke
volume, and increase cardiac output. Norepinephrine is a vasoconstrictor
used to increase blood pressure by vasoconstriction.
●● The nurse is caring for a client newly diagnosed with sepsis. The
client has a serum lactate concentration of 6 mmol/L and fluid
resuscitation has been initiated. Which value indicates that the client has
received adequate fluid resuscitation?
Answer: Mean arterial pressure of 70 mm Hg
The nurse administers fluids to achieve a target central venous pressure
of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of
0.5 mL/kg/hr, and an ScvO2 of 70%.
●● What can the nurse include in the plan of care to ensure early
intervention along the continuum of shock to improve the client's
prognosis? Select all that apply.
Answer: 1. Assess the client who is at risk for shock.
2. Administer intravenous fluids.
3. Monitor for changes in vital signs.
, Early intervention along the continuum of shock is the key to improving
the client's prognosis. The nurse must systematically assess the client at
risk for shock, recognizing subtle clinical signs of the compensatory
stage before the client's BP drops. Early interventions include identifying
the cause of shock, administering intravenous (IV) fluids and oxygen,
and obtaining necessary laboratory tests to rule out and treat metabolic
imbalances or infection. In assessing tissue perfusion, the nurse observes
for changes in level of consciousness, vital signs (including pulse
pressure), urinary output, skin, and laboratory values (e.g., base deficit
and lactic acid levels). Administering vasoconstrictive medications or
prophylactic packed red blood cells is not necessary as an early
intervention.
●● The nurse is using continuous central venous oximetry (ScvO2) to
monitor the blood oxygen saturation of a patient in shock. What value
would the nurse document as normal for the patient?
Answer: 70%
Continuous central venous oximetry (ScvO2) monitoring may be used to
evaluate mixed venous blood oxygen saturation and severity of tissue
hypoperfusion states. A central catheter is introduced into the superior
vena cava (SVC), and a sensor on the catheter measures the oxygen
saturation of the blood in the SVC as blood returns to the heart and
pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.
●● A patient in shock would exhibit which one of the following clinical
findings?
