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Shock, Sepsis & Multiple Organ Dysfunction Nclex Exam
Questions For Exam 3 Questions With Answers EXAM
2026 Latest Edition Solved Questions & Answers Verified
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pharmacology, and test-taking techniques with confidence.
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Shock, Sepsis & Multiple Organ Dysfunction NCLEX, Exam 4: Shock NCLEX
Questions, Nclex Questions for Shock - Critical Care, NCLEX Cardiac Critical Care,
Critical Care nclex, Nclex Questions for Shock - Critical Care, Shock NCLEX
Questions, Chapter 37...
The nurse is caring for a mechanically ventilated patient following insertion of
a left subclavian central venous catheter (CVC). What action by the nurse best
protects against the development of a central line associated bloodstream
infection (CLABSI)?
a. Documentation of insertion date
b. Elevation of the head of the bed
c. Assessment for weaning readiness
d. Appropriate sedation management
, Page 2 of 77
A ~ Interventions that have been associated with a reduction in CLABSI include
timely removal of unnecessary central lines. Documentation of the line insertion date
will assist in monitoring this measure. Elevation of the head of the bed, assessment
for weaning readiness, and appropriate sedation management are appropriate
interventions to reduce the risk of ventilator-acquired pneumonia.
The nurse is caring for a patient admitted with the early stages of septic shock.
The nurse assesses the patient to be tachypneic, with a respiratory rate of 32
breaths/min. Arterial blood gas values assessed on admission are pH 7.50,
CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse
indicates progression of the shock state?
a. pH 7.40, CO2 40, HCO3 24
b. pH 7.45, CO2 45, HCO3 26
c. pH 7.35, CO2 40, HCO3 22
d. pH 7.30, CO2 45, HCO3 18
D ~ As shock progresses along the continuum, acidosis ensues, caused by
metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg,
HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All
other listed arterial blood gas values are within normal limits.
The nurse is caring for a patient admitted following a motor vehicle crash.
Over the past 2 hours, the patient has received 6 units of packed red blood
cells and 4 units of fresh frozen plasma by rapid infusion. To prevent
complications, what is the priority nursing intervention?
a. Administer pain medication.
b. Turn patient every 2 hours.
c. Assess core body temperature.
d. Apply bilateral heel protectors.
C ~ Hypothermia is anticipated during the rapid infusion of fluids or blood products.
Assessment of core body temperature is a priority. While administration of pain
management, repositioning the patient every 2 hours, and application of heel
protectors should be part of the patient care, given the rapid transfusion of blood
products, these interventions are not the priority in this scenario.
The nurse is caring for a patient in cardiogenic shock who is being treated
with an infusion of dobutamine (Dobutrex). The physician's order calls for the
nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The
, Page 3 of 77
nurse measures a cardiac output, and the calculated cardiac index for the
patient is 4.6 L/min/m2. What is the best action by the nurse?
a. Obtain a stat serum potassium level.
b. Order a stat 12-lead electrocardiogram.
c. Reduce the rate of dobutamine (Dobutrex).
d. Assess the patient's hourly urine output.
C ~ Dobutamine (Dobutrex) is used to stimulate contractility and heart rate while
causing vasodilation in low cardiac output states improving overall cardiac
performance. The patients cardiac index is well above normal limits, so the rate of
infusion of the medication should be reduced so as not to overstimulate the heart.
There is no evidence to support the need for a serum potassium or 12-lead
electrocardiogram. Assessment of hourly urine output is important in the care of the
patient in cardiogenic shock, but it is not a priority in this scenario.
After receiving a handoff report from the night shift, the nurse completes the
morning assessment of a patient with severe sepsis. Vital sign assessment
notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32
breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask,
temperature 101.5 F, central venous pressure (CVP/RAP) 2 mm Hg, and urine
output of 10 mL for the past hour. The nurse initiates which active physician
order first?
a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if
the CVP is < 5 mm Hg.
b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%.
c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine
output is less than 30 mL/hr.
d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as
needed to treat temperature > 101 F.
A ~ Fluid volume resuscitation is the priority in patients with severe sepsis to
maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-
mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg
and hourly urine output of 10 mL/hr. There is no evidence to support the need to
increase supplemental oxygen. Administration of furosemide (Lasix) in the presence
of a fluid volume deficit is contraindicated.
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The nurse is caring for a patient with severe sepsis who was resuscitated with
3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory
results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best
interpretation of these findings by the nurse?
a. Blood transfusion with packed red blood cells is required.
b. Hemoglobin and hematocrit results indicate hemodilution.
c. Fluid resuscitation has resulted in fluid volume overload.
d. Fluid resuscitation has resulted in third spacing of fluid.
B ~ Fluid resuscitation with large volumes of crystalloid results in hemodilution of red
blood cells and plasma proteins. Hemoglobin and hematocrit results indicate
hemodilution. Given the clinical scenario, there is no evidence to support the need
for a blood transfusion and no evidence of fluid overload. Although administration of
large volumes of crystalloid can result in hemodilution of plasma proteins leading to
third spacing of fluid, this fact does not support the hemoglobin and hematocrit
results.
15 minutes after beginning a transfusion of O negative blood to a patient in
shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm
Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of
102 F. The nurse notes the new onset of hematuria in the patient's Foley
catheter. What are the priority nursing actions? (SATA)
a. Administer acetaminophen (Tylenol).
b. Document the patient's response.
c. Increase the rate of transfusion.
d. Notify the blood bank.
e. Notify the physician.
f. Stop the transfusion.
B, D, E, F ~ In the event of a reaction, the transfusion is stopped, the patient is
assessed, and both the physician and laboratory are notified. All transfusion
equipment (bag, tubing, and remaining solutions) and any blood or urine specimens
obtained are sent to the laboratory according to hospital policy. The events of the
reaction, interventions used, and patient response to treatment are documented.
Acetaminophen is not warranted in the immediate recognition and treatment of a
transfusion reaction. The infusion must be stopped. Increasing the infusion further
increases the likelihood of worsening the transfusion reaction.
Shock, Sepsis & Multiple Organ Dysfunction Nclex Exam
Questions For Exam 3 Questions With Answers EXAM
2026 Latest Edition Solved Questions & Answers Verified
PASS YOUR NCLEX ON YOUR FIRST ATTEMPT!
I help nursing students master NCLEX strategies, critical thinking, SATA questions,
pharmacology, and test-taking techniques with confidence.
Join my coaching program today and prepare smarter, not harder.
Contact:
Shock, Sepsis & Multiple Organ Dysfunction NCLEX, Exam 4: Shock NCLEX
Questions, Nclex Questions for Shock - Critical Care, NCLEX Cardiac Critical Care,
Critical Care nclex, Nclex Questions for Shock - Critical Care, Shock NCLEX
Questions, Chapter 37...
The nurse is caring for a mechanically ventilated patient following insertion of
a left subclavian central venous catheter (CVC). What action by the nurse best
protects against the development of a central line associated bloodstream
infection (CLABSI)?
a. Documentation of insertion date
b. Elevation of the head of the bed
c. Assessment for weaning readiness
d. Appropriate sedation management
, Page 2 of 77
A ~ Interventions that have been associated with a reduction in CLABSI include
timely removal of unnecessary central lines. Documentation of the line insertion date
will assist in monitoring this measure. Elevation of the head of the bed, assessment
for weaning readiness, and appropriate sedation management are appropriate
interventions to reduce the risk of ventilator-acquired pneumonia.
The nurse is caring for a patient admitted with the early stages of septic shock.
The nurse assesses the patient to be tachypneic, with a respiratory rate of 32
breaths/min. Arterial blood gas values assessed on admission are pH 7.50,
CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse
indicates progression of the shock state?
a. pH 7.40, CO2 40, HCO3 24
b. pH 7.45, CO2 45, HCO3 26
c. pH 7.35, CO2 40, HCO3 22
d. pH 7.30, CO2 45, HCO3 18
D ~ As shock progresses along the continuum, acidosis ensues, caused by
metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg,
HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All
other listed arterial blood gas values are within normal limits.
The nurse is caring for a patient admitted following a motor vehicle crash.
Over the past 2 hours, the patient has received 6 units of packed red blood
cells and 4 units of fresh frozen plasma by rapid infusion. To prevent
complications, what is the priority nursing intervention?
a. Administer pain medication.
b. Turn patient every 2 hours.
c. Assess core body temperature.
d. Apply bilateral heel protectors.
C ~ Hypothermia is anticipated during the rapid infusion of fluids or blood products.
Assessment of core body temperature is a priority. While administration of pain
management, repositioning the patient every 2 hours, and application of heel
protectors should be part of the patient care, given the rapid transfusion of blood
products, these interventions are not the priority in this scenario.
The nurse is caring for a patient in cardiogenic shock who is being treated
with an infusion of dobutamine (Dobutrex). The physician's order calls for the
nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The
, Page 3 of 77
nurse measures a cardiac output, and the calculated cardiac index for the
patient is 4.6 L/min/m2. What is the best action by the nurse?
a. Obtain a stat serum potassium level.
b. Order a stat 12-lead electrocardiogram.
c. Reduce the rate of dobutamine (Dobutrex).
d. Assess the patient's hourly urine output.
C ~ Dobutamine (Dobutrex) is used to stimulate contractility and heart rate while
causing vasodilation in low cardiac output states improving overall cardiac
performance. The patients cardiac index is well above normal limits, so the rate of
infusion of the medication should be reduced so as not to overstimulate the heart.
There is no evidence to support the need for a serum potassium or 12-lead
electrocardiogram. Assessment of hourly urine output is important in the care of the
patient in cardiogenic shock, but it is not a priority in this scenario.
After receiving a handoff report from the night shift, the nurse completes the
morning assessment of a patient with severe sepsis. Vital sign assessment
notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32
breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask,
temperature 101.5 F, central venous pressure (CVP/RAP) 2 mm Hg, and urine
output of 10 mL for the past hour. The nurse initiates which active physician
order first?
a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if
the CVP is < 5 mm Hg.
b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%.
c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine
output is less than 30 mL/hr.
d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as
needed to treat temperature > 101 F.
A ~ Fluid volume resuscitation is the priority in patients with severe sepsis to
maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-
mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg
and hourly urine output of 10 mL/hr. There is no evidence to support the need to
increase supplemental oxygen. Administration of furosemide (Lasix) in the presence
of a fluid volume deficit is contraindicated.
, Page 4 of 77
The nurse is caring for a patient with severe sepsis who was resuscitated with
3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory
results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best
interpretation of these findings by the nurse?
a. Blood transfusion with packed red blood cells is required.
b. Hemoglobin and hematocrit results indicate hemodilution.
c. Fluid resuscitation has resulted in fluid volume overload.
d. Fluid resuscitation has resulted in third spacing of fluid.
B ~ Fluid resuscitation with large volumes of crystalloid results in hemodilution of red
blood cells and plasma proteins. Hemoglobin and hematocrit results indicate
hemodilution. Given the clinical scenario, there is no evidence to support the need
for a blood transfusion and no evidence of fluid overload. Although administration of
large volumes of crystalloid can result in hemodilution of plasma proteins leading to
third spacing of fluid, this fact does not support the hemoglobin and hematocrit
results.
15 minutes after beginning a transfusion of O negative blood to a patient in
shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm
Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of
102 F. The nurse notes the new onset of hematuria in the patient's Foley
catheter. What are the priority nursing actions? (SATA)
a. Administer acetaminophen (Tylenol).
b. Document the patient's response.
c. Increase the rate of transfusion.
d. Notify the blood bank.
e. Notify the physician.
f. Stop the transfusion.
B, D, E, F ~ In the event of a reaction, the transfusion is stopped, the patient is
assessed, and both the physician and laboratory are notified. All transfusion
equipment (bag, tubing, and remaining solutions) and any blood or urine specimens
obtained are sent to the laboratory according to hospital policy. The events of the
reaction, interventions used, and patient response to treatment are documented.
Acetaminophen is not warranted in the immediate recognition and treatment of a
transfusion reaction. The infusion must be stopped. Increasing the infusion further
increases the likelihood of worsening the transfusion reaction.
