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WorksheetsN3SS3 Sepsis Wrap-up
Total questions: 14
Worksheet time: 11mins
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
Poor tissue perfusion
Blood glucose levels less than 120
Which statement is TRUE about the cold and warm stages of shock?
In cold shock, the body raises systemic vascular resistance and has increased cardiac output
Cold shock is more commonly seen in children with decreased cardiac output and cool extremities
Warm shock is more commonly seen in older adults and rarely requires vasopressor treatment
Cold shock is the first stage of compensated shock, and leads to uncompensated warm shock
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. 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)
O2 sats >92%
Urine output 25 mL/hr
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 24
GCS 10
HR 102
Metabolic acidosis
What is the definition of septic shock in adults?
a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality
a state of cellular and tissue hypoxia due to reduced oxygen delivery
low cardiac output state of circulatory failure that results in end-organ hypoperfusion and tissue hypoxia
life-threatening organ dysfunction caused by a dysregulated host response to infection
When should vasopressors be considered for a pediatric patient in septic shock?
When lactate levels persistently drop
Upon first signs of hypotension with a positive blood culture
In the absence of fluid overload
When shock persists after fluid bolus
When is the 4-2-1 rule used?
Calculation of fluid bolus dosage for infants with sepsis
Calculation of fluid maintenance therapy for pediatrics
Calculation of intake and output
Ratio of IV therapy (NS to Ringers to D5W) for fluid resuscitation
Hypotension in children in healthcare systems WITHOUT intensive care is defined as (choose 2):
SBP < 60 mm Hg in children aged < 12 months
SBP < 60 mm Hg in children aged 1 to 5 years
SBP drop of >20 mm Hg in infants and children
Presence of cold extremities, prolonged capillary refill > 3 seconds, and weak/fast pulse
When looking at signs of sepsis in older adults, what is considered a "febrile response"?
Only fevers >38 C
Only fevers >37.3 C
Body temperature rise greater than 1 degree C from baseline
Body temperature rise greater than 2 degree C from baseline
When compared to older adults in the community, older adults in long-term care facilities:
Are at a lower risk for sepsis due to ongoing monitoring
Have lower rates of ICU admissions as infection is detected early
Are screened more frequently for signs of sepsis
Are more likely to have a longer hospital stay
If the child is in septic shock and venous access has not been established within 5 minutes, what intervention should occur first?
Oral rehydration fluids should be encouraged
A PICC should be inserted when physician is available
Interosseous access should be obtained
NG should be inserted for oral rehydration
Which of the following is NOT a qSOFA criteria?
Mental status: GCS <15
HR >100
RR of 22 or greater
SBP 100 mm Hg or less
Which of the following screening tools should not be used alone as a single screening tool for sepsis or septic shock?
SIRS
qSOFA
MEWS
NEWS
What is the primary reason for Mean-Arterial Pressure (MAP) measurement and monitoring in sepsis?
To evaluate oxygen saturation and gas exchange efficiency
To determine if the patient is adequately perfusing vital organs
To assess the patient’s electrolyte and fluid balance
To monitor for signs of respiratory compensation in metabolic acidosis
