NCLEX QUESTIONS FOR SHOCK, SEPSIS &
MULTIPLE ORGAN DYSFUNCTION NCLEX, EXAM
4: NCLEX QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES
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 ~ Vital signs and hemodynamic values assessed collectively include classic signs and
symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing
to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4
L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not
volume overload, as evidenced by excessive hourly chest drainage and urine output.
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
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,d. Packed red blood cells
C ~ The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such
as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and
plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused
when the volume loss is caused by a loss of plasma rather than blood, such as in burns,
peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space,
causing interstitial and intracellular edema and are not used for fluid resuscitation. There is
no evidence to support a transfusion in the given scenario.
The nurse is caring for a patient in the early stages of septic shock. The patient is slightly
confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the
nurse most likely to assess?
a. High pulmonary artery occlusive pressure and high cardiac output
b. High systemic vascular resistance and low cardiac output
c. Low pulmonary artery occlusive pressure and low cardiac output
d. Low systemic vascular resistance and high cardiac output
D ~ As a consequence of the massive vasodilation associated with septic shock, in the early
stages, cardiac output is high with low systemic vascular resistance. In septic shock,
pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock,
systemic vascular resistance is low and cardiac output is high. In the early stages of septic
shock, cardiac output is high.
The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates
thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing
action?
a. Assess the blood pressure by Doppler.
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,b. Estimate the systolic pressure as 60 mm Hg.
c. Obtain an electronic blood pressure monitor.
d. Record the blood pressure as not assessable.
A ~ Auscultated blood pressures in shock may be significantly inaccurate due to
vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by
palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic
blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a
compromised patient in shock. Documenting a blood pressure as not assessable is not
appropriate without further attempts using different modalities.
The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-
directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of
fluid therapy, which physiological parameters would be most important for the nurse to
assess?
a. Breath sounds and capillary refill
b. Blood pressure and oral temperature
c. Oral temperature and capillary refill
d. Right atrial pressure and urine output
D ~ Early goal-directed therapy includes administration of IV fluids to keep central venous
pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can
be adequately assessed. Evaluation of breath sounds assists with determining fluid overload
in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a
quick assessment of the patient's overall cardiovascular status, but this assessment is not
reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of
oral temperature does not assess the effectiveness of fluid therapy in patients in shock.
Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in
shock. Capillary refill provides a quick assessment of the patient's overall cardiovascular
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, status, but this assessment is not reliable in a patient who is hypothermic or has peripheral
circulatory problems.
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 ~ Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep
RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than
110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-
spectrum antibiotics are recommended within the first hour; however, volume resuscitation is
the priority in this scenario.
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
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MULTIPLE ORGAN DYSFUNCTION NCLEX, EXAM
4: NCLEX QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES
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 ~ Vital signs and hemodynamic values assessed collectively include classic signs and
symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing
to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4
L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not
volume overload, as evidenced by excessive hourly chest drainage and urine output.
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
Page | 1
,d. Packed red blood cells
C ~ The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such
as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and
plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused
when the volume loss is caused by a loss of plasma rather than blood, such as in burns,
peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space,
causing interstitial and intracellular edema and are not used for fluid resuscitation. There is
no evidence to support a transfusion in the given scenario.
The nurse is caring for a patient in the early stages of septic shock. The patient is slightly
confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the
nurse most likely to assess?
a. High pulmonary artery occlusive pressure and high cardiac output
b. High systemic vascular resistance and low cardiac output
c. Low pulmonary artery occlusive pressure and low cardiac output
d. Low systemic vascular resistance and high cardiac output
D ~ As a consequence of the massive vasodilation associated with septic shock, in the early
stages, cardiac output is high with low systemic vascular resistance. In septic shock,
pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock,
systemic vascular resistance is low and cardiac output is high. In the early stages of septic
shock, cardiac output is high.
The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates
thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing
action?
a. Assess the blood pressure by Doppler.
Page | 2
,b. Estimate the systolic pressure as 60 mm Hg.
c. Obtain an electronic blood pressure monitor.
d. Record the blood pressure as not assessable.
A ~ Auscultated blood pressures in shock may be significantly inaccurate due to
vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by
palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic
blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a
compromised patient in shock. Documenting a blood pressure as not assessable is not
appropriate without further attempts using different modalities.
The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-
directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of
fluid therapy, which physiological parameters would be most important for the nurse to
assess?
a. Breath sounds and capillary refill
b. Blood pressure and oral temperature
c. Oral temperature and capillary refill
d. Right atrial pressure and urine output
D ~ Early goal-directed therapy includes administration of IV fluids to keep central venous
pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can
be adequately assessed. Evaluation of breath sounds assists with determining fluid overload
in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a
quick assessment of the patient's overall cardiovascular status, but this assessment is not
reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of
oral temperature does not assess the effectiveness of fluid therapy in patients in shock.
Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in
shock. Capillary refill provides a quick assessment of the patient's overall cardiovascular
Page | 3
, status, but this assessment is not reliable in a patient who is hypothermic or has peripheral
circulatory problems.
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 ~ Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep
RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than
110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-
spectrum antibiotics are recommended within the first hour; however, volume resuscitation is
the priority in this scenario.
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
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