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NSG 201H -Shock and Sepsis Assignment
NSG 201H -Shock and Sepsis Assignment
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 |
NSG 201H -Shock and Sepsis Assignment
____ 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 |
NSG 201H -Shock and Sepsis Assignment
____ 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.” |
NSG 201H -Shock and Sepsis Assignment
____ 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 |
| 3) | Preventing cardiogenic shock |
| 4) | Reducing blood pressure |
____ 15. The nurse is providing care for a patient receiving treatment for cardiogenic shock. Which assessment finding indicates that the compensatory mechanism of vasoconstriction has occurred in this patient?
| 1) | Increased heart rate |
| 2) | Increased injection fraction |
| 3) | Decreased urine output |
| 4) | Decreased temperature |
____ 16. The nurse is providing care to a patient who is admitted with cardiogenic shock. The nurse administers the prescribed atropine with no results. Which prescription does the nurse anticipate from the health-care provider based on this data?
| 1) | A beta blocker |
| 2) | Transcutaneous pacing |
| 3) | Cardiac defibrillation |
| 4) | A preload reducer |
____ 17. The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is appropriate for this patient during the initial compensatory phase?
| 1) | Placing a cool blanket over the patient |
| 2) | Raising the patient’s head to a 30-degree angle |
| 3) | Positioning the patient in the left-lateral recumbent position |
| 4) | Turning the patient’s head to one side if no neck injury is suspected |
____ 18. During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing the patient?
| 1) | Lethargy |
| 2) | Hypotension |
| 3) | Respiratory alkalosis |
| 4) | Subtle changes in heart rate |
____ 19. The nurse is providing care to a patient admitted to the emergency department (ED) with a gunshot wound and profound blood loss. Which order does the nurse anticipate for this patient?
| 1) | Normal saline |
| 2) | Dextrose in water |
| 3) | Packed red blood cells |
| 4) | Albumin |
____ 20. A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most appropriate?
| 1) | Starting an 18-gauge intravenous catheter in the patient’s nondominant hand |
| 2) | Ordering a type and cross-match of packed red blood cells |
| 3) | Preparing to assist with central line placement |
| 4) | Inserting a nasogastric tube |
NSG 201H -Shock and Sepsis Assignment
____ 21. The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic, hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient?
| 1) | Starting two large intravenous catheters |
| 2) | Notifying the Rapid Response Team |
| 3) | Calling the patient’s physician to report the changes |
| 4) | Placing oxygen on the patient |
____ 22. A patient in neurogenic shock is receiving rapid intravenous fluids. Which assessment finding indicates the need for additional nursing interventions?
| 1) | The patient’s mean arterial pressure (MAP) is 60 mmHg. |
| 2) | The patient is unconscious. |
| 3) | The patient has received two liters of infused fluid. |
| 4) | The patient is perspiring heavily. |
____ 23. Which is the highest priority nursing action when providing care to a patient with shock?
| 1) | Starting two large intravenous catheters |
| 2) | Recognizing early clinical manifestations |
| 3) | Administering high-flow oxygen |
| 4) | Calling for help immediately |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. Which will the nurse closely monitor due to the pathophysiology associated with early shock? Select all that apply.
| 1) | Bowel sounds |
| 2) | Level of consciousness |
| 3) | Urine output |
| 4) | Peripheral pulses |
| 5) | Heart rate |
____ 25. Which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock? Select all that apply.
| 1) | Pallor |
| 2) | Increased bowel sounds |
| 3) | Restlessness |
| 4) | Decreased blood glucose |
| 5) | Increased respiratory rate |
____ 26. A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with early septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply.
| 1) | Shallow respirations |
| 2) | Normal blood pressure |
| 3) | Warm and flushed skin |
| 4) | Lethargic mental status |
| 5) | Decreased urine output |
| 6) | Rapid and deep respirations |
____ 27. A patient is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this patient? Select all that apply.
| 1) | Pain |
| 2) | Fever |
| 3) | Edema |
| 4) | Anorexia |
| 5) | Tachycardia |
____ 28. A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with late septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply.
| 1) | Shallow respirations |
| 2) | Lethargic mental status |
| 3) | Decreased urine output |
| 4) | Normal blood pressure |
| 5) | Warm and flushed skin |
| 6) | Rapid and deep respirations |
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____ 29. The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment findings support the nurse’s concern? Select all that apply.
| 1) | Rapid weak pulse |
| 2) | Normal respirations |
| 3) | Normal blood pressure |
| 4) | Slight increase in pulse |
| 5) | Prolonged capillary refill time |
____ 30. A patient is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this patient for when administering the infusion? Select all that apply.
| 1) | Confusion |
| 2) | Tachycardia |
| 3) | Disorientation |
| 4) | Muscle spasms |
| 5) | Gastrointestinal bleeding |