Chapter 14.

Chapter 14: Overview of Shock and Sepsis
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing an educational session on sepsis. Which should the
nurse include as a major risk factor for the development of this health problem?
1. Immunosuppression
2. Elevated temperature
3. Pneumococcal bacteria
4. Leukocytosis on the complete blood count
____ 2. The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue
Perfusion as being appropriate for a patient with septicemia. Which intervention will
address this patient’s health problem?
1. Monitor for cyanosis.
2. Monitor heart rate every hour.
3. Assess temperature every four hours.
4. Monitor pupil reactions every eight hours.
____ 3. An older adult patient is recovering in the intensive care unit (ICU) from
septicemia. Which intervention will help prevent further infection for this patient?
1. Provide oral and skin care
2. Implement sterile wound care
3. Encourage turn, cough, and deep breathe every shift.
4. Place the Foley drainage on the bed at the patient’s feet
____ 4. A patient is prescribed epinephrine for the prevention of anaphylactic shock.
The patient states, “I thought shock was about heart failure.” Which response by the
nurse is most appropriate?
1. “There are many kinds of shock that also include infection, nervous system damage,
and loss of blood.”
2. “Heart failure is the most serious kind of shock; others include infection, kidney
failure, and loss of blood.”
3. “There are many kinds of shock: heart failure, nervous system damage, loss of blood,
and respiratory failure.”
4. “Allergic response is the most fatal type of shock; other types involve loss of blood,
heart failure, and liver failure.”

, ____ 5. An older adult patient is experiencing hypovolemic shock. Which is the
priority intervention for this patient?
1. Assessing the cause of bleeding
2. Providing replacement of volume
3. Establishing invasive cardiac monitoring
4. Administering analgesics for control of pain
____ 6. The nurse has just completed the assessment of a patient admitted with a
gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this
patient?
1. Ineffective Coping
2. Deficient Fluid Volume
3. Decreased Cardiac Output
4. Ineffective Airway Clearance
____ 7. The nurse is administering albumin 5% to a patient in shock. Which nursing
action is appropriate when assessing this patient?
1. Auscultate breath sounds for crackles
2. Auscultate breath sounds for hyperresonance
3. Auscultate breath sounds for inspiratory stridor
4. Auscultate for an absence of breath sounds in the lower lobes
____ 8. The nurse explains the purpose of an infusion of albumin 5% to a patient
recovering from hypovolemic shock. Which statement indicates that the patient
understands the instructions?
1. “It is a protein that pulls water into my blood vessels.”
2. “It is a protein that causes my kidneys to conserve fluid.”
3. “It is a super-concentrated salt solution that helps me conserve body fluid.”
4. “It is a liquid that has electrolytes in it to pull water into my blood vessels.”
____ 9. A patient being treated for hypovolemic shock is prescribed a low dose of
dopamine. Which outcome does the nurse anticipate for this patient?
1. Increased cardiac output
2. Stabilization of fluid loss
3. Urinary output of at least 30 mL/hour
4. Vasoconstriction and increased blood pressure

, ____ 10. A nurse is caring for a patient who was involved in a motor vehicle accident
who has lost approximately 1,500 mL of blood. Based on this data, which type of
shock is the patient experiencing?
1. Hypovolemic
2. Cardiogenic
3. Distributive
4. Obstructive
____ 11. A nurse working in the intensive care unit (ICU) is caring for a patient in
refractory stage of shock. When planning care, which does the nurse anticipate?
1. A subtle change in heart rate
2. A change from aerobic to anaerobic metabolism
3. The development of hyperglycemia
4. The development of cardiac dysrhythmias
____ 12. The nurse is preparing to administer diphenhydramine to a patient who is
experiencing a severe allergic reaction to peanuts. Which information about the drug
should the nurse provide to the patient?
1. “This is the medication of choice to treat airway obstruction.”
2. “This medication will help relieve your itching and runny nose.”
3. “This medication will prevent you from going into anaphylactic shock.”
4. “This medication will take a while to be effective but will control your symptoms for
several hours.”
____ 13. The nurse is conducting medication teaching for a patient who is prescribed
an epi-pen. Which statements made by the patient indicates the need for additional
instruction?
1. “I will carry an epi-pen with me at all times.”
2. “I will check the expiration date on my epi-pen regularly.”
3. “I should hold the epi-pen in place for 10 seconds after injection.”
4. “I should use the epi-pen to inject the drug into my abdominal wall.”
____ 14. The nurse is providing care to a patient who is admitted to the emergency
department with symptoms of a myocardial infarction (MI). Which is the primary
purpose of the interventions administered to this patient?
1. Providing pain relief
2. Preventing extension of damage