**The Septic Sentinel: Prioritizing
Perfusion in Critical Care**
Question 1
A client with sepsis has a serum lactate of 4.2 mmol/L and mean arterial pressure (MAP) of 58 mm Hg.
Which intervention should the nurse implement first?
A. Administer prescribed norepinephrine
B. Obtain blood cultures
C. Start broad-spectrum antibiotics
D. Initiate a 30 mL/kg crystalloid bolus
---
💫RATIONALE✔️✔️: Sepsis guidelines prioritize rapid volume resuscitation within 3 hours for hypotension
and hyperlactatemia, as improving preload directly enhances perfusion.
💫ANSWER✔️✔️: D. Initiate a 30 mL/kg crystalloid bolus
Question 2
A client is 4 hours post-hip replacement and reports sudden shortness of breath with chest pain. Spo2 is
88% on room air. What is the priority action?
A. Reassure client and reposition to left side
B. Apply oxygen at 2 L/min via nasal cannula
C. Assess surgical site for bleeding
D. Prepare for STAT ventilation/perfusion scan
---
💫RATIONALE✔️✔️: Sudden hypoxia and chest pain post-op suggest pulmonary embolism; applying
oxygen addresses hypoxemia first, then diagnosis is pursued.
💫ANSWER✔️✔️: B. Apply oxygen at 2 L/min via nasal cannula
Question 3
,A client with heart failure has jugular venous distention, 3+ pitting edema, and crackles bilaterally.
Which PRN medication is most appropriate?
A. Metoprolol 25 mg PO
B. Furosemide 40 mg IV
C. Digoxin 0.125 mg IV
D. Spironolactone 25 mg PO
---
💫RATIONALE✔️✔️: IV loop diuretics like furosemide rapidly reduce preload, relieving pulmonary
congestion and edema in acute decompensated heart failure.
💫ANSWER✔️✔️: B. Furosemide 40 mg IV
Question 4
A nurse receives report on four clients. Which should be assessed first?
A. Client with diabetes and blood glucose of 58 mg/dL, alert and diaphoretic
B. Client with COPD and oxygen saturation of 89% on 2 L/min
C. Client with pneumonia and temperature of 38.9°C (102°F)
D. Client with C. difficile and 10 episodes of diarrhea in 8 hours
---
💫RATIONALE✔️✔️: Hypoglycemia (glucose <70) poses immediate risk of neurological deterioration if
untreated; diaphoresis indicates sympathetic activation.
💫ANSWER✔️✔️: A. Client with diabetes and blood glucose of 58 mg/dL, alert and diaphoretic
Question 5
A client on a heparin drip develops epistaxis and bruising. PTT is 110 seconds (therapeutic range 60-80).
Which medication should the nurse anticipate?
A. Vitamin K
B. Protamine sulfate
C. Andexanet alfa
D. Fresh frozen plasma
---
,💫RATIONALE✔️✔️: Protamine sulfate specifically neutralizes unfractionated heparin by binding to it,
reversing anticoagulation in bleeding with elevated PTT.
💫ANSWER✔️✔️: B. Protamine sulfate
Question 6
Which finding in a client receiving IV vancomycin requires immediate nursing action?
A. Red man syndrome on the chest and neck
B. Serum creatinine increase from 0.9 to 1.6 mg/dL
C. Trough level of 12 mcg/mL
D. Phlebitis at the IV site
---
💫RATIONALE✔️✔️: Vancomycin is nephrotoxic; a rising serum creatinine signals acute kidney injury,
requiring dose adjustment and monitoring.
💫ANSWER✔️✔️: B. Serum creatinine increase from 0.9 to 1.6 mg/dL
Question 7
A client with major burns develops increasing hoarseness, stridor, and subcostal retractions. Which
action takes priority?
A. Prepare for endotracheal intubation
B. Adminute nebulized racemic epinephrine
C. Elevate the head of bed to 45 degrees
D. Obtain arterial blood gases
---
💫RATIONALE✔️✔️: Hoarseness and stridor after burns indicate impending upper airway edema and
obstruction; immediate intubation secures the airway before complete closure.
💫ANSWER✔️✔️: A. Prepare for endotracheal intubation
Question 8
A postpartum client with a firm fundus and lochia rubra saturates one perineal pad every 15 minutes.
What is the nurse’s priority?
, A. Document as normal heavy lochia
B. Massage the fundus again
C. Notify the provider immediately
D. Encourage voiding every 2 hours
---
💫RATIONALE✔️✔️: Excessive bleeding (>1 pad/hour) despite a firm fundus suggests lower genital tract
trauma or retained fragments; immediate notification is required.
💫ANSWER✔️✔️: C. Notify the provider immediately
Question 9
A client receiving a blood transfusion develops fever, chills, and low back pain 30 minutes after start.
Which action is most important?
A. Slow the transfusion rate to 50 mL/hr
B. Administer acetaminophen as ordered
C. Stop the transfusion and disconnect tubing
D. Check for compatibility documents
---
💫RATIONALE✔️✔️: Back pain, fever, chills suggest acute hemolytic reaction; stopping the transfusion
immediately prevents further hemolysis and acute kidney injury.
💫ANSWER✔️✔️: C. Stop the transfusion and disconnect tubing
Question 10
The nurse is teaching a client with chronic kidney disease (stage 4). Which statement indicates correct
understanding of phosphorus management?
A. “I will take my calcium acetate with each meal.”
B. “I should eat more dairy products for protein.”
C. “Phosphorus binders work best on an empty stomach.”
D. “I will restrict fluids to prevent swelling.”
---
Perfusion in Critical Care**
Question 1
A client with sepsis has a serum lactate of 4.2 mmol/L and mean arterial pressure (MAP) of 58 mm Hg.
Which intervention should the nurse implement first?
A. Administer prescribed norepinephrine
B. Obtain blood cultures
C. Start broad-spectrum antibiotics
D. Initiate a 30 mL/kg crystalloid bolus
---
💫RATIONALE✔️✔️: Sepsis guidelines prioritize rapid volume resuscitation within 3 hours for hypotension
and hyperlactatemia, as improving preload directly enhances perfusion.
💫ANSWER✔️✔️: D. Initiate a 30 mL/kg crystalloid bolus
Question 2
A client is 4 hours post-hip replacement and reports sudden shortness of breath with chest pain. Spo2 is
88% on room air. What is the priority action?
A. Reassure client and reposition to left side
B. Apply oxygen at 2 L/min via nasal cannula
C. Assess surgical site for bleeding
D. Prepare for STAT ventilation/perfusion scan
---
💫RATIONALE✔️✔️: Sudden hypoxia and chest pain post-op suggest pulmonary embolism; applying
oxygen addresses hypoxemia first, then diagnosis is pursued.
💫ANSWER✔️✔️: B. Apply oxygen at 2 L/min via nasal cannula
Question 3
,A client with heart failure has jugular venous distention, 3+ pitting edema, and crackles bilaterally.
Which PRN medication is most appropriate?
A. Metoprolol 25 mg PO
B. Furosemide 40 mg IV
C. Digoxin 0.125 mg IV
D. Spironolactone 25 mg PO
---
💫RATIONALE✔️✔️: IV loop diuretics like furosemide rapidly reduce preload, relieving pulmonary
congestion and edema in acute decompensated heart failure.
💫ANSWER✔️✔️: B. Furosemide 40 mg IV
Question 4
A nurse receives report on four clients. Which should be assessed first?
A. Client with diabetes and blood glucose of 58 mg/dL, alert and diaphoretic
B. Client with COPD and oxygen saturation of 89% on 2 L/min
C. Client with pneumonia and temperature of 38.9°C (102°F)
D. Client with C. difficile and 10 episodes of diarrhea in 8 hours
---
💫RATIONALE✔️✔️: Hypoglycemia (glucose <70) poses immediate risk of neurological deterioration if
untreated; diaphoresis indicates sympathetic activation.
💫ANSWER✔️✔️: A. Client with diabetes and blood glucose of 58 mg/dL, alert and diaphoretic
Question 5
A client on a heparin drip develops epistaxis and bruising. PTT is 110 seconds (therapeutic range 60-80).
Which medication should the nurse anticipate?
A. Vitamin K
B. Protamine sulfate
C. Andexanet alfa
D. Fresh frozen plasma
---
,💫RATIONALE✔️✔️: Protamine sulfate specifically neutralizes unfractionated heparin by binding to it,
reversing anticoagulation in bleeding with elevated PTT.
💫ANSWER✔️✔️: B. Protamine sulfate
Question 6
Which finding in a client receiving IV vancomycin requires immediate nursing action?
A. Red man syndrome on the chest and neck
B. Serum creatinine increase from 0.9 to 1.6 mg/dL
C. Trough level of 12 mcg/mL
D. Phlebitis at the IV site
---
💫RATIONALE✔️✔️: Vancomycin is nephrotoxic; a rising serum creatinine signals acute kidney injury,
requiring dose adjustment and monitoring.
💫ANSWER✔️✔️: B. Serum creatinine increase from 0.9 to 1.6 mg/dL
Question 7
A client with major burns develops increasing hoarseness, stridor, and subcostal retractions. Which
action takes priority?
A. Prepare for endotracheal intubation
B. Adminute nebulized racemic epinephrine
C. Elevate the head of bed to 45 degrees
D. Obtain arterial blood gases
---
💫RATIONALE✔️✔️: Hoarseness and stridor after burns indicate impending upper airway edema and
obstruction; immediate intubation secures the airway before complete closure.
💫ANSWER✔️✔️: A. Prepare for endotracheal intubation
Question 8
A postpartum client with a firm fundus and lochia rubra saturates one perineal pad every 15 minutes.
What is the nurse’s priority?
, A. Document as normal heavy lochia
B. Massage the fundus again
C. Notify the provider immediately
D. Encourage voiding every 2 hours
---
💫RATIONALE✔️✔️: Excessive bleeding (>1 pad/hour) despite a firm fundus suggests lower genital tract
trauma or retained fragments; immediate notification is required.
💫ANSWER✔️✔️: C. Notify the provider immediately
Question 9
A client receiving a blood transfusion develops fever, chills, and low back pain 30 minutes after start.
Which action is most important?
A. Slow the transfusion rate to 50 mL/hr
B. Administer acetaminophen as ordered
C. Stop the transfusion and disconnect tubing
D. Check for compatibility documents
---
💫RATIONALE✔️✔️: Back pain, fever, chills suggest acute hemolytic reaction; stopping the transfusion
immediately prevents further hemolysis and acute kidney injury.
💫ANSWER✔️✔️: C. Stop the transfusion and disconnect tubing
Question 10
The nurse is teaching a client with chronic kidney disease (stage 4). Which statement indicates correct
understanding of phosphorus management?
A. “I will take my calcium acetate with each meal.”
B. “I should eat more dairy products for protein.”
C. “Phosphorus binders work best on an empty stomach.”
D. “I will restrict fluids to prevent swelling.”
---
