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WorksheetsShock & Sepsis
Total questions: 20
Worksheet time: 2hrs 34mins
Dopamine at 1-5 mcg/kg/min increases ____, 5-10 makes it a ____, > 10 turns it into a ____
(a)
The nurse understands the importance of early recognition of SIRS (systemic inflammatory response syndrome) in a client with sepsis because once activated, SIRS results in the following physiological changes: (SATA)
Increased capillary permeability
Vasodilation
Suppression of the immune response
Poor tissue perfusion
Blood glucose levels less than 120
Which embodies the warm phase of septic shock? (SATA)
↑ CO, ↓ SVR
↓ CO, ↑ SVR
Vasodilation due to endotoxins
Vasoconstriction
↑ CVP, PAP, & PCWP due to stasis of blood
Which nursing intervention is most important in preventing septic shock?
Obtaining vital signs every 4 hours for all clients
Monitoring RBC levels for elevation
Maintaining asepsis of indwelling urinary catheters
Administering IV fluid replacement as prescribed
The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply.
Drop in systolic blood pressure of 40 mm Hg from baselines
Hypotension that responds to bolus fluid resuscitation
Exaggerated response to vasoactive medications
Serum lactate >4 mmol/L
Mean arterial pressure (MAP) of 65 mm Hg
A nurse is caring for a patient with sepsis-induced hypoperfusion. She starts an IV infusion of 30 mL/kg of NS within the first 3 hours as stated in sepsis guidelines. What measurable outcomes would let the nurse know that adequate fluid volume replacement has been achieved?
MAP ≥ 65 mm Hg
CVP 4-8 mm Hg (normal CVP 1-8)
ScVO2 ≥ 70%
Urine output 25 mL/hr
List the Sepsis Bundle in order of priority (top 5). Then list at least 1 value (a point involving a number) under each section.
(a)
Besides the main points of the Sepsis Bundle, list 4 ways the nurse would manage someone in shock.
(a)
The nurse is caring for a patient diagnosed with hypovolemic shock. Which of the following signs & symptoms would alert the nurse that the patient has entered the progressive stage of shock? Select all that apply.
Diffuse petechiae
BP 86/53
MAP of 67
Cardiac Output 5 (normal 4-8)
pH 7.31, PaCO2 51, PaO2 89, HCO3 25
The client who does not respond adequately to fluid replacement has a prescribed order for an IV infusion of dopamine hydrochloride at 8 mcg/kg/min. The expected outcome the nurse should expect at this dose would be…
Decreased preload.
Increased renal and mesenteric blood flow.
Increased stroke volume.
Vasoconstriction.
Which ABG results would a nurse expect to see for a client who is in the early stages of shock?
pH 7.35, PaCO2 48, PaO2 95, HCO3- 20
pH 7.44, PaCO2 32, PaO2 96, HCO3- 20
pH 7.30, PaCO2 50, PaO2 92, HCO3- 26
pH 7.23, PaCO2 45, PaO2 90, HCO3- 18
A client returns from surgery following a transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH). Which of the assessment findings would cause the nurse to suspect postoperative hemorrhage?
Increased blood pressure, bounding pulse, irregular respirations
Fluctuating blood pressure, decreased pulse, rapid respirations
Increased blood pressure, irregular pulse, shallow respirations
Decreased blood pressure, increased pulse, increased respirations
A nurse is caring for a patient diagnosed with septic shock. Which signs & symptoms would indicate that the patient is now in the cold phase of septic shock? Select all that apply.
Cold, clammy skin
CVP 12 (normal 1-8)
Urine output less than 0.5 mL/kg/hr
Cardiac output 2 (normal 4-8)
SVR 1500 (normal 800-1200)
A nurse has received the laboratory work of a patient who is suspected to have hypovolemic shock. What would be the laboratory findings if the patient is in the early stages of hypovolemic shock? Select all that apply.
Metabolic acidosis
Increased sodium levels
Increased liver enzymes
Increased glucose levels
Decreased potassium levels
Which of the following assessment findings would alert the nurse that a client in sepsis has activated SIRS (systemic inflammatory response syndrome)? Select all that apply.
PaCO2 30 mmHg
Respiratory rate of 20
Leukocytes 8,000 mm3
Change in mentation
Temperature 38.4 C (101.1 F)
A nurse is caring for a patient diagnosed with hypovolemic shock. The patient is suspected of being in the irreversible stage. Which of the following would attribute to this stage of shock? Select all that apply.
2 or more organs altered / failing
Profound alkalosis
Mechanical ventilation in use
Hyperstimulated
Jaundice
Which of the following are true regarding vasopressors? Select all that apply.
Arterial line is needed
Preload will increase
Epinephrine is preferred
Used when fluid challenge fails & MAP is > 65
Vasopressin is used when norepinephrine (Levohphed) has reached max dose
Which of the following signs & symptoms are representative of the compensatory stage of shock? Select all that apply.
HR 110
Confusion
BP 110/90
Warm and dry
Respiratory alkalosis
Which of the following would suggest that the patient has developed sepsis according to a qSOFA evaluation? Select all that apply.
BP 96/74
RR 21
GCS 10
HR 90
Metabolic acidosis
Which of the following are signs & symptoms of a patient in the initial stage of shock?
Tenting skin
Asymptomatic
Respiratory alkalosis
HR > 90
Cold, clammy skin
