Sepsis
True or False
Sepsis is a regulated host response to infection.
False
In septic shock (select all that apply)
A- Life threatening organ dysfunction
B-Increase mortality rate
C- Lactate level is more than 4 mmol/L
D- Patient needs to intubated
A, B, C
True/False
Cardiogenic shock is involved with pump blood and tissue oxygenation
True
A- Inflammatory response
B- Renin-Angiotensi response
C- Lymphatic system
A
A- Increased venous return
B- Decreased intravascular volume
C- Increased cardiac output
D- No change in tissue perfusion
B
The first lactate level in a sepsis patient was 2.5 mmol/L, do we need to check another level
A- Yes
B- No
A- Yes
Within 6 hours
A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first?
a. Obtain two sets of blood cultures.
b. Administer the prescribed IV vancomycin (Vancocin).
c. Obtain central venous pressure (CVP) measurements.
d. Administer the prescribed IV norepinephrine (Levophed).
a. Obtain two sets of blood cultures.
Why do we use Nitroglycerin in Cardiogenic shock?
A- Vasodilation and decrease pre load
B- Increase contractility
C- Antiarrhythmic
D- Increase blood pressure
A- Vasodilation and decrease pre load
Which medication is part of treatment in anaphylactic shock?
A-Epinephrine
B-Dobutamine
C- Adenosine
D- Morphine
A-Epinephrine
The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what is the priority intervention for this client?
a. Administer an aminoglycoside.
b. Initiate a dopamine hydrochloride (Intropin) drip.
c. Administer crystalloid fluids.
d. Initiate an intravenous heparin drip.
c. Administer crystalloid fluids.
The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102 F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first?
a. Acetaminophen suppository
b. Blood cultures from two sites
c. IV antibiotic administration
d. Isotonic fluid challenge
d. Isotonic fluid challenge
Why do we use Levophed after fluid resuscitation in septic shock patients:
A- Increase cardiac output
B- Decrease systematic pressure
C- Increase contractility
A- Increase cardiac output
After a cariogenic shock, the patient lost the functionality of kidneys and dialysis started. What do we call this complication:
A- Acute kidney problem
B-Chronic kidney problem
C- Multiple organ dysfunction syndrome
C
After fluid replacement for a patient with hypovolemic shock a patient showed fluid overload, what are the signs and symptoms, select all that apply
A- Asculate crackles
B- Low blood pressure
C- Low oxygenation
D- Swollen
A, C, D
Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?
a. A patient admitted with abdominal pain and an elevated white blood cell count
b. A patient with a temperature of 102 F and a general dermal rash
c. A patient with a 2-day history of nausea, vomiting, and diarrhea
d. A patient with slight rectal bleeding from inflamed hemorrhoids
c. A patient with a 2-day history of nausea, vomiting, and diarrhea
The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action?
a. Creatinine 1.0 mg/dL
b. Lactate 6 mmol/L
c. Potassium 3.8 mEq/L
d. Sodium 140 mEq/L
b. Lactate 6 mmol/L
The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first?
a. Blood cultures
b. Chest x-ray
c. Foley insertion
d. Serum electrolytes
a. Blood cultures
When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion
to treat cardiogenic shock, which finding indicates that the medication is effective?
a. No heart murmur is audible.
b. Skin is warm, pink, and dry.
c. Troponin level is decreased.
d. Blood pressure is 90/40 mm Hg.
ANS: B
Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since
nitroprusside is a vasodilator, the blood pressure may be low even if the medication is
effective.
The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock?
a. "Is your blood pressure higher than usual?"
b. "Are you having pain in your throat?"
c. "Have you been vomiting?"
d. "Are you usually this swollen?"
D. "Are you usually this swollen?"
A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention?
a. Human albumin infusion
b. Hypotonic saline solution
c. Lactated Ringer's bolus
d. Packed red blood cells
c. Lactated Ringer's bolus
A patient with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in first step
30 ml/kg, about 3390
A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the client's systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first?
a. Insert a Foley catheter to monitor urine output closely.
b. Ask the client's family to come to the hospital because death is near.
c. Initiate the prescribed dobutamine (Dobutrex) intravenous drip.
d. Obtain blood cultures before administering the next dose of antibiotics.
c. Initiate the prescribed dobutamine (Dobutrex) intravenous drip.
A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess?
a. High pulmonary artery diastolic pressure and low cardiac output
b. Low pulmonary artery occlusive pressure and low cardiac output
c. Low systemic vascular resistance and high cardiac output
d. Normal cardiac output and low systemic vascular resistance
A ~ In cardiogenic shock, cardiac output and cardiac index decrease.
Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention?
a. Diphenhydramine (Benadryl) 50 mg intravenously
b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously
c. Methylprednisolone (Solu-Medrol) 125 mg intravenously
d. Ranitidine (Zantac) 50 mg intravenously
b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously
A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse?
a. The assessed values are within normal limits.
b. The patient is at risk for developing cardiogenic shock.
c. The patient is at risk for developing fluid volume overload.
d. The patient is at risk for developing hypovolemic shock.
d. The patient is at risk for developing hypovolemic shock.