Lewis’s ATI Medical-Surgical 12th Edition Chapter 42 Shock,
Sepsis, and Multiple Organ Dysfunction Syndrome Harding:
Knowledge test Exam Toolkit Questions and Verified solution
2025/2026
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
CORRECT ANSWER: 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.
When the nurse educator is evaluating the skills of a new registered nurse (RN) caring
for patients experiencing 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. Increasing the nitroprusside (Nipride) infusion rate for a patient with a
high SVR
d. Maintaining the room temperature at 66 to 68 F for a patient with
neurogenic shock
,CORRECT ANSWER: D
Patients with neurogenic shock may have poikilothermia. The room temperature should
be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.
A patient is admitted to the emergency department (ED) in shock of unknown etiology.
Which action would the nurse take first (or The first action by the nurse should be to)?
a. Obtain the blood pressure.
b. Check the level of orientation.
c. Administer supplemental oxygen.
d. Obtain a 12-lead electrocardiogram.
CORRECT ANSWER: 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
accomplished as rapidly as possible after providing O2.
During change-of-shift report, the nurse is told that 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?
OR
A patient has been admitted with dehydration and hypotension after 4 days of vomiting
and diarrhea. Which finding is most important for the nurse to report to the health care
provider?
a. New onset of confusion
,b. Heart rate 112 beats/minute
c. Decreased bowel sounds
d. Pale, cool, and dry extremities
CORRECT ANSWER: 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.
A patient who was 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 would 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 tr correct answerfusions.
d. Initiate continuous electrocardiogram (ECG) monitoring.
CORRECT ANSWER: 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 tr correct
answerfusions
should also be rapidly accomplished but only after actions to maximize O2 delivery have
been implemented.
The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine)
infusion through a right forearm IV. Which assessment finding obtained by the nurse
indicates a need for immediate action?
, OR
A patient who has neurogenic shock is receiving phenylephrine through a right forearm
IV. Which assessment finding obtained by the nurse indicates a need for immediate
action?
a. The patients heart rate is 58 beats/minute.
b. The patients extremities are warm and dry.
c. The patients IV infusion site is cool and pale.
d. The patients urine output is 28 mL over the last hour.
CORRECT ANSWER: 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 medication into a central
line. An apical pulse of 58 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.
The following interventions are ordered by the health care provider for a patient who has
respiratory distress and syncope after eating strawberries. Which will the nurse
complete first?
a. Start a normal saline infusion.
b. Give epinephrine (Adrenalin).
c. Start continuous ECG monitoring.
d. Give diphenhydramine (Benadryl).
CORRECT ANSWER: B
Sepsis, and Multiple Organ Dysfunction Syndrome Harding:
Knowledge test Exam Toolkit Questions and Verified solution
2025/2026
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
CORRECT ANSWER: 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.
When the nurse educator is evaluating the skills of a new registered nurse (RN) caring
for patients experiencing 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. Increasing the nitroprusside (Nipride) infusion rate for a patient with a
high SVR
d. Maintaining the room temperature at 66 to 68 F for a patient with
neurogenic shock
,CORRECT ANSWER: D
Patients with neurogenic shock may have poikilothermia. The room temperature should
be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.
A patient is admitted to the emergency department (ED) in shock of unknown etiology.
Which action would the nurse take first (or The first action by the nurse should be to)?
a. Obtain the blood pressure.
b. Check the level of orientation.
c. Administer supplemental oxygen.
d. Obtain a 12-lead electrocardiogram.
CORRECT ANSWER: 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
accomplished as rapidly as possible after providing O2.
During change-of-shift report, the nurse is told that 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?
OR
A patient has been admitted with dehydration and hypotension after 4 days of vomiting
and diarrhea. Which finding is most important for the nurse to report to the health care
provider?
a. New onset of confusion
,b. Heart rate 112 beats/minute
c. Decreased bowel sounds
d. Pale, cool, and dry extremities
CORRECT ANSWER: 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.
A patient who was 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 would 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 tr correct answerfusions.
d. Initiate continuous electrocardiogram (ECG) monitoring.
CORRECT ANSWER: 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 tr correct
answerfusions
should also be rapidly accomplished but only after actions to maximize O2 delivery have
been implemented.
The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine)
infusion through a right forearm IV. Which assessment finding obtained by the nurse
indicates a need for immediate action?
, OR
A patient who has neurogenic shock is receiving phenylephrine through a right forearm
IV. Which assessment finding obtained by the nurse indicates a need for immediate
action?
a. The patients heart rate is 58 beats/minute.
b. The patients extremities are warm and dry.
c. The patients IV infusion site is cool and pale.
d. The patients urine output is 28 mL over the last hour.
CORRECT ANSWER: 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 medication into a central
line. An apical pulse of 58 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.
The following interventions are ordered by the health care provider for a patient who has
respiratory distress and syncope after eating strawberries. Which will the nurse
complete first?
a. Start a normal saline infusion.
b. Give epinephrine (Adrenalin).
c. Start continuous ECG monitoring.
d. Give diphenhydramine (Benadryl).
CORRECT ANSWER: B
