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HESI Specialty Exam Bank on Management of Sepsis and Infection Control Protocols
, 2
Subtopic 1: Early Recognition and Assessment of Sepsis
(Questions 1–20)
1. A patient in the emergency department presents with a temperature of 39.2°C (102.6°F),
heart rate of 118 bpm, respiratory rate of 24 breaths per minute, and WBC count of
15,000/mm³. What is the nurse's priority interpretation of these findings?
A. Possible electrolyte imbalance
B. Early signs of renal failure
C. Indicators of Systemic Inflammatory Response Syndrome (SIRS)
D. Normal stress response
Correct Answer: C
Rationale: These are hallmark criteria for SIRS, which is often the first phase of sepsis.
Recognizing these signs early is crucial to preventing progression.
2. Which of the following is the most reliable early clinical indicator of septic shock?
A. Decreased urine output
B. Cyanotic extremities
C. Persistent hypotension despite fluid resuscitation
D. Bradycardia
Correct Answer: C
Rationale: Septic shock is characterized by hypotension that persists despite adequate
fluid resuscitation, indicating a need for vasopressors.
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3. The nurse assesses a patient with suspected sepsis. Which finding best supports a
diagnosis of sepsis rather than a localized infection?
A. Redness and swelling at the IV site
B. Temperature of 100.8°F (38.2°C)
C. Lactate level of 3.2 mmol/L
D. Mild discomfort at the wound
Correct Answer: C
Rationale: An elevated lactate level indicates tissue hypoperfusion, a systemic effect
suggesting sepsis.
4. In screening for sepsis, which of the following bedside tools is most recommended in the
current Surviving Sepsis Guidelines for rapid assessment?
A. APACHE II Score
B. Glasgow Coma Scale
C. qSOFA Score
D. Braden Scale
Correct Answer: C
Rationale: The qSOFA (quick Sequential Organ Failure Assessment) is a rapid bedside
screening tool used to identify patients at high risk for sepsis.
5. A septic patient has a MAP (mean arterial pressure) of 58 mmHg. What should the nurse
anticipate next?
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A. Administering acetaminophen
B. Starting vasopressor therapy
C. Withholding fluids
D. Encouraging oral intake
Correct Answer: B
Rationale: A MAP below 65 mmHg after fluid resuscitation requires vasopressors to
maintain organ perfusion.
6. Which of the following is a hallmark laboratory finding that indicates worsening sepsis?
A. Low creatinine
B. Hypoglycemia
C. Elevated procalcitonin
D. Low hemoglobin
Correct Answer: C
Rationale: Procalcitonin is a biomarker that increases significantly in bacterial infections
and sepsis progression.
7. What is the purpose of obtaining blood cultures before antibiotic administration in a
septic patient?
A. To rule out viral infections
B. To monitor renal function
C. To identify causative organisms and guide therapy
D. To verify antibiotic resistance
HESI Specialty Exam Bank on Management of Sepsis and Infection Control Protocols
, 2
Subtopic 1: Early Recognition and Assessment of Sepsis
(Questions 1–20)
1. A patient in the emergency department presents with a temperature of 39.2°C (102.6°F),
heart rate of 118 bpm, respiratory rate of 24 breaths per minute, and WBC count of
15,000/mm³. What is the nurse's priority interpretation of these findings?
A. Possible electrolyte imbalance
B. Early signs of renal failure
C. Indicators of Systemic Inflammatory Response Syndrome (SIRS)
D. Normal stress response
Correct Answer: C
Rationale: These are hallmark criteria for SIRS, which is often the first phase of sepsis.
Recognizing these signs early is crucial to preventing progression.
2. Which of the following is the most reliable early clinical indicator of septic shock?
A. Decreased urine output
B. Cyanotic extremities
C. Persistent hypotension despite fluid resuscitation
D. Bradycardia
Correct Answer: C
Rationale: Septic shock is characterized by hypotension that persists despite adequate
fluid resuscitation, indicating a need for vasopressors.
, 3
3. The nurse assesses a patient with suspected sepsis. Which finding best supports a
diagnosis of sepsis rather than a localized infection?
A. Redness and swelling at the IV site
B. Temperature of 100.8°F (38.2°C)
C. Lactate level of 3.2 mmol/L
D. Mild discomfort at the wound
Correct Answer: C
Rationale: An elevated lactate level indicates tissue hypoperfusion, a systemic effect
suggesting sepsis.
4. In screening for sepsis, which of the following bedside tools is most recommended in the
current Surviving Sepsis Guidelines for rapid assessment?
A. APACHE II Score
B. Glasgow Coma Scale
C. qSOFA Score
D. Braden Scale
Correct Answer: C
Rationale: The qSOFA (quick Sequential Organ Failure Assessment) is a rapid bedside
screening tool used to identify patients at high risk for sepsis.
5. A septic patient has a MAP (mean arterial pressure) of 58 mmHg. What should the nurse
anticipate next?
, 4
A. Administering acetaminophen
B. Starting vasopressor therapy
C. Withholding fluids
D. Encouraging oral intake
Correct Answer: B
Rationale: A MAP below 65 mmHg after fluid resuscitation requires vasopressors to
maintain organ perfusion.
6. Which of the following is a hallmark laboratory finding that indicates worsening sepsis?
A. Low creatinine
B. Hypoglycemia
C. Elevated procalcitonin
D. Low hemoglobin
Correct Answer: C
Rationale: Procalcitonin is a biomarker that increases significantly in bacterial infections
and sepsis progression.
7. What is the purpose of obtaining blood cultures before antibiotic administration in a
septic patient?
A. To rule out viral infections
B. To monitor renal function
C. To identify causative organisms and guide therapy
D. To verify antibiotic resistance
