NCLEX SIRS and MODS

Question 1

A 78-kg patient in septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. After initial fluid volume resuscitation, the patient’s urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question?

a. Administer furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Give hydrocortisone (Solu-Cortef) 100 mg IV.
d. Use norepinephrine to keep systolic BP above 90 mm Hg.

Answer 1

ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock need large amounts of fluid replacement. If the patient is still hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.

Question 2

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and a high pulmonary artery wedge pressure (PAWP). Which intervention prescribed by the health care provider should the nurse question?

a. Elevate head of bed to 30 degrees.
b. Infuse normal saline at 250 mL/hr.
c. Hold nitroprusside if systolic BP is less than 90 mm Hg.
d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

Answer 2

ANS: B
The patient’s elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will worsen the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.

Question 3

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?

a. Inspiratory crackles
b. Heart rate 45 beats/min
c. Cool, clammy extremities
d. Temperature 101.2° F (38.4° C)

Answer 3

ANS: B
Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Question 4

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?

a. Increase the rate for the dopamine infusion.
b. Decrease the rate for the nitroglycerin infusion.
c. Increase the rate for the sodium nitroprusside infusion.
d. Decrease the rate for the 5% dextrose in normal saline infusion.

Answer 4

ANS: C
Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

Question 5

After a patient who has septic shock receives 2 L of normal saline intravenously, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. What medication should the nurse anticipate?

a. Furosemide
b. Nitroglycerin
c. Norepinephrine
d. Sodium nitroprusside

Answer 5

ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

Question 6

To evaluate the effectiveness of the pantoprazole (Protonix) given to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?

a. Auscultate bowel sounds.
b. Ask the patient about nausea.
c. Check stools for occult blood.
d. Palpate for abdominal tenderness.

Answer 6

ANS: C
Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

Question 7

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is high, and cardiac output is low. Which treatment would the nurse expect to be prescribed?

a. Furosemide
b. Hydrocortisone
c. Epinephrine drip
d. 5% albumin infusion

Answer 7

ANS: A
The PAWP indicates that the patient’s preload is elevated. Furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

Question 8

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. What should the nurse obtain in preparation for the patient’s arrival?

a. A dopamine infusion
b. A hypothermia blanket
c. Lactated Ringer’s solution
d. Two 16-gauge IV catheters

Answer 8

ANS: D
A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer’s solution should be used cautiously and would not be prescribed until the patient has been assessed for liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

Question 9

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?

a. There are no signs of hemorrhage.
b. Hemoglobin is within normal limits.
c. Urine output 65 mL over the past hour.
d. Mean arterial pressure (MAP) is 72 mm Hg.

Answer 9

ANS: C
Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.

Question 10

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

a. Check temperature every 2 hours.
b. Monitor breath sounds frequently.
c. Maintain patient in supine position.
d. Assess skin for flushing and itching.

Answer 10

ANS: B
Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Question 11

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

a. The patient is receiving low dose dopamine.
b. The patient’s central venous pressure is 3 mm Hg.
c. The patient is in sinus tachycardia at 120 beats/min.
d. The patient has had no urine output since admission.

Answer 11

ANS: B
Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient’s low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

Question 12

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?

a. No heart murmur
b. Skin is warm and pink
c. Decreased troponin level
d. Blood pressure of 92/40 mm Hg

Answer 12

ANS: B
Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

Question 13

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?

a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation

Answer 13

ANS: D
Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

Question 14

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?

a. The patient’s serum creatinine level is high.
b. The patient reports intermittent chest pressure.
c. The patient’s extremities are cool, and pulses are 1+.
d. The patient has bilateral crackles throughout lung fields

Answer 14

ANS: A
The high serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient’s diagnosis of cardiogenic shock

Question 15

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104° F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

a. Acetaminophen (Tylenol) 650 mg rectally.
b. Administer normal saline IV at 500 mL/hr.
c. Start norepinephrine to keep blood pressure above 90 mm Hg.
d. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL

Answer 15

ANS: B
Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

Question 16

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients with shock, which action by the new RN indicates a need for more education?

a. Placing the pulse oximeter on the ear for a patient with septic shock
b. Keeping the head of the bed flat for a patient with hypovolemic shock
c. Maintaining a cool room temperature for a patient with neurogenic shock
d. Increasing the nitroprusside for a patient with cardiogenic shock and a high SVR

Answer 16

ANS: C
Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

Question 17

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?

a. Skin cool and clammy
b. Heart rate of 118 beats/min
c. Blood pressure of 92/56 mm Hg
d. O2 saturation of 93% on room air

Answer 17

ANS: A
Because patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported but does not indicate deterioration of the patient’s status.

Question 18

A patient is admitted to the emergency department (ED) in shock of unknown etiology. What should be the nurse’s first action?

a. Obtain the blood pressure.
b. Check the level of orientation.
c. Administer supplemental oxygen.
d. Obtain a 12-lead electrocardiogram.

Answer 18

ANS: C
The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be done as rapidly as possible after providing O2.

Question 19

A patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?

a. New onset of confusion
b. Decreased bowel sounds
c. Heart rate 112 beats/min
d. Pale, cool, and dry extremities

Answer 19

ANS: A
The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

Question 20

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first?

a. Insert two large-bore IV catheters.
b. Provide O2 at 100% per non-rebreather mask.
c. Draw blood to type and crossmatch for transfusions.
d. Initiate continuous electrocardiogram (ECG) monitoring.

Answer 20

ANS: B
The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented.

Question 21

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?

a. The patient’s heart rate is 58 beats/min.
b. The patient’s extremities are warm and dry.
c. The patient’s IV infusion site is cool and pale.
d. The patient’s urine output is 28 mL over the past hour.

Answer 21

ANS: C
The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

Question 22

The following interventions are prescribed by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?

a. Give diphenhydramine.
b. Administer epinephrine.
c. Start continuous ECG monitoring.
d. Draw blood for complete blood count.

Answer 22

ANS: B
Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.

Question 23

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider?

a. The patient’s urine output is 18 mL/hr.
b. The patient’s heart rate is 110 beats/min.
c. The patient’s peripheral pulses are weak.
d. The patient reports diffuse chest pressure.

Answer 23

ANS: D
Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion and cause chest pain or pressure. Low urine output, weal pulses, and tachycardia are consistent with the patient’s diagnosis. They and should be reported to the health care provider but do not require an immediate need for a change in therapy

Question 24

After change-of-shift report in the progressive care unit, who should the nurse care for first?

a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases.
b. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/min.
c. Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics.
d. Patient admitted with anaphylaxis 3 hours ago who has clear lung sounds and a blood pressure of 108/58 mm Hg.

Answer 24

ANS: C
Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not need immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually need treatment in patients with a spinal cord injury. The findings for the patient admitted with anaphylaxis show resolution of bronchospasm and hypotension.

Question 25

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider?
Physical Assessment: petechiae noted on chest and legs, crackles heard bilaterally in lung bases, no redness or swelling at central IV site.
Lab: BUN 34 mg/dL, Hct 30%, Plts 50,000/uL
V/s: Temp 100 F (37.8 C), Pulse 102/min, RR: 26/min, BP 110/60 mmHg, O2 sat 93% on 2L O2 via nasal cannula
a. Temperature and IV site appearance
b. Oxygen saturation and breath sounds
c. Platelet count and presence of petechiae
d. Blood pressure, pulse rate, respiratory rate

Answer 25

ANS: C
The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will be discussed with the health care provider but does not show that the patient’s condition is deteriorating or that a change in therapy is needed immediately.

Question 26

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take? (Select all that apply.)

a. Prepare to administer atropine IV.
b. Obtain baseline body temperature.
c. Infuse large volumes of lactated Ringer’s solution.
d. Provide high-flow O2 (100%) by nonrebreather mask.
e. Prepare for emergent intubation and mechanical ventilation.

Answer 26

ANS: A, B, D, E
All the actions are appropriate except to give large volumes of lactated Ringer’s solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer’s solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.

Question 27

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? (Select all that apply.)

a. Ambulate postoperative patients as soon as possible after surgery.
b. Use aseptic technique when manipulating invasive lines or devices.
c. Remove indwelling urinary catheters as soon as possible after surgery.
d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

Answer 27

ANS: A, B, C, D
Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

Question 28

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many milliliters per hour?

Answer 28

ANS:
27
198 lb = 90 kg. To administer the dobutamine at the prescribed rate of 5 mcg/kg/min from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hr.

Question 29

The health care provider prescribes the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].)

a. Obtain blood and urine cultures.
b. Give vancomycin by IV infusion.
c. Start norepinephrine 0.5 mcg/min.
d. Infuse normal saline 2000 mL over 30 minutes.
e. Administer oxygen to keep O2 saturation above 95%.

Answer 29

ANS:
E, D, C, A, B
The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics.