Vitals
How long should you count respirations for a patient with an irregular respiratory rhythm?
Which laboratory value is commonly monitored to assess tissue hypoperfusion and response to treatment in patients with sepsis
Lactate
Which body system is the first priority when assessing a patient?
Respiratory
What finding most strongly suggests neurogenic shock rather than hypovolemic shock?
A. Hypotension
B. Decreased cardiac output
C. Bradycardia
D. Altered mental status
Bradycardia
Because most other shock states activate the sympathetic nervous system and produce tachycardia, while neurogenic shock does the opposite due to loss of sympathetic tone.
What acronym do we follow for identifying stroke symptoms?
BEFAST
Greater than 20 breaths per minute.
What is often the earliest sign of septic shock in a child?
A. Hypotension
B. Bradycardia
C. Tachycardia
D. Cyanosis
Tachycardia
Children can compensate for shock for a long time. Tachycardia is often one of the earliest signs, while hypotension is a late and ominous finding.
Name 1 of 3 fundamental types of assessments nurses perform
Comprehensive/interval or abbreviated (BSSR)/problem-focused assessment
A patient presents with:
What type of shock
neurogenic
60 minutes
15
True or False: A patient can have sepsis without a fever.
True
Older adults, immunocompromised patients, and critically ill patients may present with hypothermia, confusion, or weakness instead of fever, making nursing assessment crucial.
The Primary assessment follows what specific sequence
ABCDE
Name 1 of 3 types of shock
Hypovolemia, distributive (including sepsis), obstructive
Which assessment finding is most suggestive of a right hemispheric stroke?
Left sided neglect
What is the definition of oliguria
Decreased urine output of less than 400 mL in 24 hour period.
Which assessment finding would suggest progression from sepsis to septic shock?
A. Fever and tachycardia B. Elevated WBC count C. Hypotension despite adequate fluid resuscitation D. Positive blood cultures
C. Hypotension despite adequate fluid resuscitation
What is one of the earliest signs of a patient having deteroriation
Mental status changes are often the earliest sign of deterioration.
At what serum lactate level should a nurse become particularly concerned about severe sepsis or septic shock?
Greater than 2, trending upward
A patient has sudden vision loss, aphasia, and right-sided weakness. Which side of the brain is most likely affected?
Left Hemisphere
What is one of the earliest vital signs to change in a deteriorating patient
Respiratory rate
What is the outside ICU screening tool for Sepsis?
qSOFA (Quick Sequential Organ Failure Assessment)
What is the deteroriation index and why is it important?
RRT at DI uses AI to notice slight changes documented in the chart that may show signs of a patient deteriorating before recognized by the team
Which type of shock is most likely to present with elevated jugular venous distention (JVD), hypotension, clear lung sounds
Obstructive shock (cardiac tamponade)
Which complication is a leading cause of mortality in stroke patients during hospitalization?
Aspiration pneumonia