Shock and Sepsis NCLEX questions | UPDATED Questions
with 100% Verified Answers
Bevill State Community College • NUR 211
Q1: The nurse is caring for postoperative clients at risk for hypovolemic shock. Which of the following would
cause the nurse to suspect that the client has early shock? A. Hypotension B. Bradypnea C. Irregular heart
rhythm D. Tachycardia
A: A. Hypotension
Q2: When caring for an obtunded ED client with shock of unknown origin, which action should the nurse
take first? A. Establish IV access and hang prescribed infusion B. Apply the automatic BP cuff C. Assess
level of consciousness and pupil response to light D. Check the airway and respiratory status
A: D. Check the airway and respiratory status
When caring for any client, determining airway and respiratory status is the priority. The
airway takes priority over obtaining IV access, applying the blood pressure cuff, and
assessing for changes in the client's mental status.
Q3: The nursing assistant reports concerns about the postoperative client who has BP 90/60, HR 80, R 22.
What should the RN do? A. Compare these VS with last several readings B. Request that the surgeon come
see the client C. Increase the rate of IV fluids D. Reassess VS using different equipment
A: A. Compare these vital signs with the last several readings.
Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may be normal
for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is
not indicated. The same equipment should be used when vital signs are taken
postoperatively.
Q4: A postoperative client is admitted to the ICU with hypovolemic shock. Which nursing action should the
nurse delegate to the experienced nursing assistant? A. Obtain vital signs every 15 minutes B. Measure
hourly urine output C. Check oxygen saturation D. Assess level of alertness
A: B. Measure hourly urine output
Monitoring hourly urine output is included in nursing assistant education and does not
require special clinical judgment; the nurse evaluates the results. Obtaining vital signs,
monitoring oxygen saturation, and assessing mental status in critically ill clients requires
the clinical judgment of the critical care nurse because immediate intervention may be
needed.
, Q5: When caring for client with hypovolemic shock with these assessment findings, T 97.9, P 122, R 24, BP
86/48, total urine output 20mL in last 2 hours, skin cool and clammy, which of the following orders would the
nurse question? A. Dopamine (Intropin) 12mcg/kg/min B. Dobutamine (Dobutrex) 5mcg/kg/min C. Plasmanate
1 unit D. Bumetanide (Bumex) 1mg IV
A: D. Bumetanide (Bumex) 1mg IV
A diuretic such as bumetanide will decrease blood volume in a client who is already
hypovolemic; this order should be questioned because this is not an appropriate action
to expand the client's blood volume. The other orders are appropriate for improving
blood pressure in shock, and do not need to be questioned.
Q6: Which change in the client with hypovolemic shock indicates to the nurse that treatment is effective? A.
Urine output increases from 5mL/hr to 25mL/hr B. Pulse pressure decreases from 35mmHg to 28mmHg C.
Respiratory rate increases from 22/minute to 26/minute D. Body temperature increases from 98.2F to 98.8F
A: A. Urine output increases from 5mL/hr to 25mL/hr
We want the urine output to increase
Q7: Which of the following would indicate a positive outcome after starting dopamine (Intropin)? A. Hourly
urine output of 1018 mL B. BP 90/60 and MAP 70 C. Blood glucose 245 D. Serum creatinine 3.6mg/dL
A: B. BP 90/60 and MAP 70
Dopamine improves blood flow by increasing peripheral resistance, which increases
blood pressure—a positive response in this case. Urine output less than 30 mL/hr or 0.5
mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney
and are a negative consequence of shock, not a positive response. Although a blood
glucose of 245 mg/dL is an abnormal finding, dopamine increases blood pressure and
myocardial contractility, not glucose levels.
Q8: How does the nurse recognize that the client is in early stages of septic shock? A. Pallor and cool skin B.
Blood pressure 84/50 C. Tachypnea & tachycardia D. Respiratory acidosis
A: C. Tachypnea & tachycardia
Q9: The nurse is caring for a group of clients at risk for sepsis. Which of the following puts the client at
highest risk? A. Pernicious anemia B. Pericarditis C. Postkidney transplant D. Client owns an iguana
A: C. Postkidney transplant
Q10: Which problem places the client at highest risk for septic shock? A. Stage III Chronic Kidney Disease B.
Cirrhosis C. Lung cancer D. 40% burn injury
A: D. 40% burn injury
with 100% Verified Answers
Bevill State Community College • NUR 211
Q1: The nurse is caring for postoperative clients at risk for hypovolemic shock. Which of the following would
cause the nurse to suspect that the client has early shock? A. Hypotension B. Bradypnea C. Irregular heart
rhythm D. Tachycardia
A: A. Hypotension
Q2: When caring for an obtunded ED client with shock of unknown origin, which action should the nurse
take first? A. Establish IV access and hang prescribed infusion B. Apply the automatic BP cuff C. Assess
level of consciousness and pupil response to light D. Check the airway and respiratory status
A: D. Check the airway and respiratory status
When caring for any client, determining airway and respiratory status is the priority. The
airway takes priority over obtaining IV access, applying the blood pressure cuff, and
assessing for changes in the client's mental status.
Q3: The nursing assistant reports concerns about the postoperative client who has BP 90/60, HR 80, R 22.
What should the RN do? A. Compare these VS with last several readings B. Request that the surgeon come
see the client C. Increase the rate of IV fluids D. Reassess VS using different equipment
A: A. Compare these vital signs with the last several readings.
Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may be normal
for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is
not indicated. The same equipment should be used when vital signs are taken
postoperatively.
Q4: A postoperative client is admitted to the ICU with hypovolemic shock. Which nursing action should the
nurse delegate to the experienced nursing assistant? A. Obtain vital signs every 15 minutes B. Measure
hourly urine output C. Check oxygen saturation D. Assess level of alertness
A: B. Measure hourly urine output
Monitoring hourly urine output is included in nursing assistant education and does not
require special clinical judgment; the nurse evaluates the results. Obtaining vital signs,
monitoring oxygen saturation, and assessing mental status in critically ill clients requires
the clinical judgment of the critical care nurse because immediate intervention may be
needed.
, Q5: When caring for client with hypovolemic shock with these assessment findings, T 97.9, P 122, R 24, BP
86/48, total urine output 20mL in last 2 hours, skin cool and clammy, which of the following orders would the
nurse question? A. Dopamine (Intropin) 12mcg/kg/min B. Dobutamine (Dobutrex) 5mcg/kg/min C. Plasmanate
1 unit D. Bumetanide (Bumex) 1mg IV
A: D. Bumetanide (Bumex) 1mg IV
A diuretic such as bumetanide will decrease blood volume in a client who is already
hypovolemic; this order should be questioned because this is not an appropriate action
to expand the client's blood volume. The other orders are appropriate for improving
blood pressure in shock, and do not need to be questioned.
Q6: Which change in the client with hypovolemic shock indicates to the nurse that treatment is effective? A.
Urine output increases from 5mL/hr to 25mL/hr B. Pulse pressure decreases from 35mmHg to 28mmHg C.
Respiratory rate increases from 22/minute to 26/minute D. Body temperature increases from 98.2F to 98.8F
A: A. Urine output increases from 5mL/hr to 25mL/hr
We want the urine output to increase
Q7: Which of the following would indicate a positive outcome after starting dopamine (Intropin)? A. Hourly
urine output of 1018 mL B. BP 90/60 and MAP 70 C. Blood glucose 245 D. Serum creatinine 3.6mg/dL
A: B. BP 90/60 and MAP 70
Dopamine improves blood flow by increasing peripheral resistance, which increases
blood pressure—a positive response in this case. Urine output less than 30 mL/hr or 0.5
mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney
and are a negative consequence of shock, not a positive response. Although a blood
glucose of 245 mg/dL is an abnormal finding, dopamine increases blood pressure and
myocardial contractility, not glucose levels.
Q8: How does the nurse recognize that the client is in early stages of septic shock? A. Pallor and cool skin B.
Blood pressure 84/50 C. Tachypnea & tachycardia D. Respiratory acidosis
A: C. Tachypnea & tachycardia
Q9: The nurse is caring for a group of clients at risk for sepsis. Which of the following puts the client at
highest risk? A. Pernicious anemia B. Pericarditis C. Postkidney transplant D. Client owns an iguana
A: C. Postkidney transplant
Q10: Which problem places the client at highest risk for septic shock? A. Stage III Chronic Kidney Disease B.
Cirrhosis C. Lung cancer D. 40% burn injury
A: D. 40% burn injury
