SEPSIS NCLEX QUESTIONS WITH CORRECT
ANSWERS| SHOCK AND SEPSIS NCLEX QUESTIONS
WITH CORRECT ANSWERS
When caring for client with hypovolemic shock with these assessment findings,
T 97.9, P 122,
R 24, BP 86/48, total urine output 20mL in last 2 hours, skin cool and clammy,
which of the following orders would the nurse question?
A. Dopamine (Intropin) 12mcg/kg/min
B. Dobutamine (Dobutrex) 5mcg/kg/min
C. Plasmanate 1 unit
D. Bumetanide (Bumex) 1mg IV --CORRECT ANSWER--D. Bumetanide
(Bumex) 1mg IV
A diuretic such as bumetanide will decrease blood volume in a client who is
already hypovolemic; this order should be questioned because this is not an
appropriate action to expand the client's blood volume. The other orders are
appropriate for improving blood pressure in shock, and do not need to be
questioned.
Which change in the client with hypovolemic shock indicates to the nurse that
treatment is effective?
Page 1 of 31
,A. Urine output increases from 5mL/hr to 25mL/hr
B. Pulse pressure decreases from 35mmHg to 28mmHg
C. Respiratory rate increases from 22/minute to 26/minute
D. Body temperature increases from 98.2F to 98.8F --CORRECT ANSWER--
A. Urine output increases from 5mL/hr to 25mL/hr
We want the urine output to increase
Which of the following would indicate a positive outcome after starting
dopamine (Intropin)?
A. Hourly urine output of 10-18 mL
B. BP 90/60 and MAP 70
C. Blood glucose 245
D. Serum creatinine 3.6mg/dL --CORRECT ANSWER--B. BP 90/60 and MAP
70
Dopamine improves blood flow by increasing peripheral resistance, which
increases blood pressure—a positive response in this case. Urine output less
than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor
tissue perfusion to the kidney and are a negative consequence of shock, not a
positive response. Although a blood glucose of 245 mg/dL is an abnormal
finding, dopamine increases blood pressure and myocardial contractility, not
glucose levels.
Page 2 of 31
,How does the nurse recognize that the client is in early stages of septic shock?
A. Pallor and cool skin
B. Blood pressure 84/50
C. Tachypnea & tachycardia
D. Respiratory acidosis --CORRECT ANSWER--C. Tachypnea & tachycardia
The nurse is caring for postoperative clients at risk for hypovolemic shock.
Which of the following would cause the nurse to suspect that the client has early
shock?
A. Hypotension
B. Bradypnea
C. Irregular heart rhythm
D. Tachycardia --CORRECT ANSWER--A. Hypotension
When caring for an obtunded ED client with shock of unknown origin, which
action should the nurse take first?
A. Establish IV access and hang prescribed infusion
B. Apply the automatic BP cuff
Page 3 of 31
, C. Assess level of consciousness and pupil response to light
D. Check the airway and respiratory status --CORRECT ANSWER--D. Check
the airway and respiratory status
When caring for any client, determining airway and respiratory status is the
priority. The airway takes priority over obtaining IV access, applying the blood
pressure cuff, and assessing for changes in the client's mental status.
The nursing assistant reports concerns about the postoperative client who has
BP 90/60, HR 80, R 22. What should the RN do?
A. Compare these VS with last several readings
B. Request that the surgeon come see the client
C. Increase the rate of IV fluids
D. Reassess VS using different equipment --CORRECT ANSWER--A.
Compare these vital signs with the last several readings.
Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may
be normal for this client. Calling the surgeon is not necessary at this point, and
increasing IV fluids is not indicated. The same equipment should be used when
vital signs are taken postoperatively.
A postoperative client is admitted to the ICU with hypovolemic shock. Which
nursing action should the nurse delegate to the experienced nursing assistant?
Page 4 of 31
ANSWERS| SHOCK AND SEPSIS NCLEX QUESTIONS
WITH CORRECT ANSWERS
When caring for client with hypovolemic shock with these assessment findings,
T 97.9, P 122,
R 24, BP 86/48, total urine output 20mL in last 2 hours, skin cool and clammy,
which of the following orders would the nurse question?
A. Dopamine (Intropin) 12mcg/kg/min
B. Dobutamine (Dobutrex) 5mcg/kg/min
C. Plasmanate 1 unit
D. Bumetanide (Bumex) 1mg IV --CORRECT ANSWER--D. Bumetanide
(Bumex) 1mg IV
A diuretic such as bumetanide will decrease blood volume in a client who is
already hypovolemic; this order should be questioned because this is not an
appropriate action to expand the client's blood volume. The other orders are
appropriate for improving blood pressure in shock, and do not need to be
questioned.
Which change in the client with hypovolemic shock indicates to the nurse that
treatment is effective?
Page 1 of 31
,A. Urine output increases from 5mL/hr to 25mL/hr
B. Pulse pressure decreases from 35mmHg to 28mmHg
C. Respiratory rate increases from 22/minute to 26/minute
D. Body temperature increases from 98.2F to 98.8F --CORRECT ANSWER--
A. Urine output increases from 5mL/hr to 25mL/hr
We want the urine output to increase
Which of the following would indicate a positive outcome after starting
dopamine (Intropin)?
A. Hourly urine output of 10-18 mL
B. BP 90/60 and MAP 70
C. Blood glucose 245
D. Serum creatinine 3.6mg/dL --CORRECT ANSWER--B. BP 90/60 and MAP
70
Dopamine improves blood flow by increasing peripheral resistance, which
increases blood pressure—a positive response in this case. Urine output less
than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor
tissue perfusion to the kidney and are a negative consequence of shock, not a
positive response. Although a blood glucose of 245 mg/dL is an abnormal
finding, dopamine increases blood pressure and myocardial contractility, not
glucose levels.
Page 2 of 31
,How does the nurse recognize that the client is in early stages of septic shock?
A. Pallor and cool skin
B. Blood pressure 84/50
C. Tachypnea & tachycardia
D. Respiratory acidosis --CORRECT ANSWER--C. Tachypnea & tachycardia
The nurse is caring for postoperative clients at risk for hypovolemic shock.
Which of the following would cause the nurse to suspect that the client has early
shock?
A. Hypotension
B. Bradypnea
C. Irregular heart rhythm
D. Tachycardia --CORRECT ANSWER--A. Hypotension
When caring for an obtunded ED client with shock of unknown origin, which
action should the nurse take first?
A. Establish IV access and hang prescribed infusion
B. Apply the automatic BP cuff
Page 3 of 31
, C. Assess level of consciousness and pupil response to light
D. Check the airway and respiratory status --CORRECT ANSWER--D. Check
the airway and respiratory status
When caring for any client, determining airway and respiratory status is the
priority. The airway takes priority over obtaining IV access, applying the blood
pressure cuff, and assessing for changes in the client's mental status.
The nursing assistant reports concerns about the postoperative client who has
BP 90/60, HR 80, R 22. What should the RN do?
A. Compare these VS with last several readings
B. Request that the surgeon come see the client
C. Increase the rate of IV fluids
D. Reassess VS using different equipment --CORRECT ANSWER--A.
Compare these vital signs with the last several readings.
Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may
be normal for this client. Calling the surgeon is not necessary at this point, and
increasing IV fluids is not indicated. The same equipment should be used when
vital signs are taken postoperatively.
A postoperative client is admitted to the ICU with hypovolemic shock. Which
nursing action should the nurse delegate to the experienced nursing assistant?
Page 4 of 31
