Chapter 69: Nursing Management: Shock, Sepsis, and Multiple-Organ
Dysfunction Syndrome: Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient in the emergency department (ED) who is in shock
of unknown etiology. Which of the following actions should the nurse implement first?
A. Administer oxygen.
B. Attach a cardiac monitor.
C. Obtain the blood pressure.
D. Check the level of consciousness.
Answer: A
Explanation: Following the CAB (Circulation, Airway, Breathing) approach, ensuring a
patent airway and administering oxygen to support breathing and oxygenation is the first
priority for any patient in shock, regardless of the cause, to prevent hypoxic injury.
2. A patient who has been involved in a motor vehicle crash is admitted to the
emergency department (ED) with cool, clammy skin; tachycardia; and hypotension.
Which of the following prescribed interventions should the nurse implement first?
A. Place the patient on continuous cardiac monitor.
B. Draw blood to type and crossmatch for transfusions.
C. Insert two 14-gauge IV catheters in antecubital space.
D. Administer oxygen at 100% per non-rebreather mask.
Answer: D
Explanation: The first priority in managing any critically ill patient is the ABCs (Airway,
Breathing, Circulation). Administering high-flow oxygen addresses Breathing and is the most
immediate action to prevent hypoxia. The other actions are crucial but follow securing the
airway and breathing.
3. The following therapies are prescribed by the health care provider for a patient who
has respiratory distress and syncope after a bee sting. Which of the following actions
should the nurse implement first?
A. Normal saline infusion
B. Epinephrine
C. Dexamethasone
D. Diphenhydramine
Answer: B
Explanation: Epinephrine is the first-line treatment for anaphylactic shock. It rapidly
reverses bronchoconstriction, promotes vasoconstriction to raise blood pressure, and
counteracts the effects of histamine. The other medications are supportive but do not act as
quickly or address the core pathophysiology as directly.
4. The emergency department (ED) receives notification that a patient who has just
been in an automobile accident is being transported to your facility with anticipated
arrival in 1 minute. Which of the following should the nurse obtain in preparation for
,the patient's arrival?
A. 500 mL of 5% albumin
B. Lactated Ringer's solution
C. Two 14-gauge IV catheters
D. Dopamine infusion
Answer: C
Explanation: A trauma patient may require rapid fluid resuscitation for hypovolemic shock.
Two large-bore (14-gauge) IV catheters are essential for administering crystalloids like
normal saline quickly. Lactated Ringer's may be used cautiously, colloids are not first-line,
and vasopressors are not initial therapy for hypovolemia.
5. The nurse is caring for a patient with septic shock who has had a urine output of 20
mL/hour for the past 3 hours. The pulse rate is 120 and the central venous pressure and
pulmonary artery wedge pressure are low. Which of the following orders by the health
care provider should the nurse question?
A. Administer furosemide 40 mg IV.
B. Increase normal saline infusion to 150 mL/hour.
C. Administer hydrocortisone 100 mg IV.
D. Administer dopamine 5 mcg/kg/minute IV.
Answer: A
Explanation: Furosemide is a diuretic that will further reduce intravascular volume, lowering
filling pressures and renal perfusion, which is detrimental in a patient with septic shock who
already has low central venous pressure and pulmonary artery wedge pressure. The other
orders are appropriate for supporting blood pressure and addressing the inflammatory
response in septic shock.
6. The nurse is caring for a patient with shock whose hemodynamic monitoring
indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which
of the following prescribed interventions should the nurse question?
A. Infuse normal saline at 250 mL/hour.
B. Keep head of bed elevated to 30 degrees.
C. Give nitroglycerin unless systolic BP <90 mm Hg.
D. Administer dobutamine to keep systolic BP >90 mm Hg.
Answer: A
Explanation: An elevated pulmonary artery wedge pressure indicates volume excess.
Administering normal saline at a rapid rate would exacerbate fluid overload and potentially
worsen pulmonary congestion. The other actions are appropriate for managing a patient with
signs of volume overload and potential cardiac involvement.
7. The nurse is caring for a patient in the emergency department (ED) with massive
trauma and possible spinal cord injury. Which of the following findings by the nurse
will help confirm a diagnosis of neurogenic shock?
A. Cool, clammy skin
B. Inspiratory crackles
C. Apical heart rate 48 beats/minute
,D. Temperature 38.4°C (101.1°F)
Answer: C
Explanation: Neurogenic shock, resulting from spinal cord injury, is characterized by
hypotension and bradycardia due to unopposed parasympathetic activity. Cool, clammy skin
is typical of hypovolemic or cardiogenic shock, crackles suggest pulmonary edema, and fever
is not a specific sign of neurogenic shock.
8. The nurse is caring for a patient in noncardiogenic shock who is cool, clammy and
whose hemodynamic monitoring indicates a high systemic vascular resistance (SVR).
Which of the following actions should the nurse anticipate implementing?
A. Increase the rate for the prescribed dopamine infusion.
B. Decrease the rate for the prescribed nitroglycerin infusion.
C. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion.
D. Increase the rate for the prescribed sodium nitroprusside infusion.
Answer: D
Explanation: A high SVR indicates excessive vasoconstriction. Sodium nitroprusside is an
arterial vasodilator that will decrease SVR and afterload, improving cardiac output.
Increasing dopamine would further increase SVR, and adjustments to nitroglycerin or D5W
would not directly address the high SVR.
9. After receiving 1000 mL of normal saline, the central venous pressure for a patient
who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. Which
of the following prescribed medications should the nurse administer?
A. Nitroglycerin
B. Drotrecogin-α
C. Norepinephrine
D. Sodium nitroprusside
Answer: C
Explanation: After inadequate response to fluid resuscitation, vasopressor drugs like
norepinephrine are administered to increase systemic vascular resistance (SVR) and improve
blood pressure and tissue perfusion. Nitroglycerin and nitroprusside are vasodilators and
would worsen hypotension. Drotrecogin-α addresses inflammation but does not directly raise
blood pressure.
10. The nurse is caring for a patient with septic shock who has a BP of 70/46 mm Hg,
pulse 136, respirations 32, temperature 40°C (104°F), and blood glucose 13.7 mmol/L.
Which of the following prescribed interventions will the nurse implement first?
A. Give normal saline IV at 500 mL/hour.
B. Infuse drotrecogin-α 24 mcg/kg.
C. Start insulin drip to maintain blood glucose at 11–15 mmol/L.
D. Titrate norepinephrine to keep mean arterial pressure (MAP) at 65–70 mm Hg.
Answer: A
Explanation: The initial management of septic shock focuses on aggressive fluid
resuscitation to correct intravascular volume depletion and low systemic vascular resistance.
, Administering normal saline rapidly is the first priority to support blood pressure and organ
perfusion before initiating vasopressors or other specific therapies.
11. The nurse is caring for a patient who has septic shock. Which of the following
assessment findings is most important for the nurse to report to the health care
provider?
A. BP 92/56 mm Hg
B. Skin cool and clammy
C. Apical pulse 118 beats/minute
D. Arterial oxygen saturation 91%
Answer: B
Explanation: Early septic shock is typically characterized by warm, flushed skin due to
vasodilation. The development of cool, clammy skin indicates a worsening state, signaling
progression to a more severe stage of shock with poor perfusion and compensatory
vasoconstriction.
12. The nurse is caring for a patient who is receiving vasopressin to treat septic shock.
Which of the following assessments is most important for the nurse to communicate to
the health care provider?
A. The patient's heart rate is 108 beats/minute.
B. The patient is complaining of chest pain.
C. The patient's peripheral pulses are weak.
D. The patient's urine output is 15 mL/hour.
Answer: B
Explanation: Vasopressin is a potent vasoconstrictor and can cause coronary artery
vasoconstriction, potentially leading to myocardial ischemia. Chest pain is a critical finding
that must be reported immediately as it could indicate a serious adverse effect of the
medication. The other findings are consistent with septic shock itself.
13. Which of the following assessments should the nurse make to evaluate the
effectiveness of omeprazole administration to a patient with systemic inflammatory
response syndrome (SIRS)?
A. Auscultate bowel sounds.
B. Ask the patient about nausea.
C. Monitor stools for occult blood.
D. Check for abdominal distention.
Answer: C
Explanation: Omeprazole is a proton pump inhibitor given to reduce the risk of stress ulcers
in critically ill patients. The most direct way to evaluate its effectiveness is to monitor for the
absence of gastrointestinal bleeding, which is detected by checking stools for occult blood.
14. The nurse is caring for a patient in pulmonary edema as result of cardiogenic shock
has the following vital signs: BP 86/50, pulse 126, respirations 30. Which of the
following actions should the nurse anticipate implementing?
A. Infusion of 5% human albumin
Dysfunction Syndrome: Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient in the emergency department (ED) who is in shock
of unknown etiology. Which of the following actions should the nurse implement first?
A. Administer oxygen.
B. Attach a cardiac monitor.
C. Obtain the blood pressure.
D. Check the level of consciousness.
Answer: A
Explanation: Following the CAB (Circulation, Airway, Breathing) approach, ensuring a
patent airway and administering oxygen to support breathing and oxygenation is the first
priority for any patient in shock, regardless of the cause, to prevent hypoxic injury.
2. A patient who has been involved in a motor vehicle crash is admitted to the
emergency department (ED) with cool, clammy skin; tachycardia; and hypotension.
Which of the following prescribed interventions should the nurse implement first?
A. Place the patient on continuous cardiac monitor.
B. Draw blood to type and crossmatch for transfusions.
C. Insert two 14-gauge IV catheters in antecubital space.
D. Administer oxygen at 100% per non-rebreather mask.
Answer: D
Explanation: The first priority in managing any critically ill patient is the ABCs (Airway,
Breathing, Circulation). Administering high-flow oxygen addresses Breathing and is the most
immediate action to prevent hypoxia. The other actions are crucial but follow securing the
airway and breathing.
3. The following therapies are prescribed by the health care provider for a patient who
has respiratory distress and syncope after a bee sting. Which of the following actions
should the nurse implement first?
A. Normal saline infusion
B. Epinephrine
C. Dexamethasone
D. Diphenhydramine
Answer: B
Explanation: Epinephrine is the first-line treatment for anaphylactic shock. It rapidly
reverses bronchoconstriction, promotes vasoconstriction to raise blood pressure, and
counteracts the effects of histamine. The other medications are supportive but do not act as
quickly or address the core pathophysiology as directly.
4. The emergency department (ED) receives notification that a patient who has just
been in an automobile accident is being transported to your facility with anticipated
arrival in 1 minute. Which of the following should the nurse obtain in preparation for
,the patient's arrival?
A. 500 mL of 5% albumin
B. Lactated Ringer's solution
C. Two 14-gauge IV catheters
D. Dopamine infusion
Answer: C
Explanation: A trauma patient may require rapid fluid resuscitation for hypovolemic shock.
Two large-bore (14-gauge) IV catheters are essential for administering crystalloids like
normal saline quickly. Lactated Ringer's may be used cautiously, colloids are not first-line,
and vasopressors are not initial therapy for hypovolemia.
5. The nurse is caring for a patient with septic shock who has had a urine output of 20
mL/hour for the past 3 hours. The pulse rate is 120 and the central venous pressure and
pulmonary artery wedge pressure are low. Which of the following orders by the health
care provider should the nurse question?
A. Administer furosemide 40 mg IV.
B. Increase normal saline infusion to 150 mL/hour.
C. Administer hydrocortisone 100 mg IV.
D. Administer dopamine 5 mcg/kg/minute IV.
Answer: A
Explanation: Furosemide is a diuretic that will further reduce intravascular volume, lowering
filling pressures and renal perfusion, which is detrimental in a patient with septic shock who
already has low central venous pressure and pulmonary artery wedge pressure. The other
orders are appropriate for supporting blood pressure and addressing the inflammatory
response in septic shock.
6. The nurse is caring for a patient with shock whose hemodynamic monitoring
indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which
of the following prescribed interventions should the nurse question?
A. Infuse normal saline at 250 mL/hour.
B. Keep head of bed elevated to 30 degrees.
C. Give nitroglycerin unless systolic BP <90 mm Hg.
D. Administer dobutamine to keep systolic BP >90 mm Hg.
Answer: A
Explanation: An elevated pulmonary artery wedge pressure indicates volume excess.
Administering normal saline at a rapid rate would exacerbate fluid overload and potentially
worsen pulmonary congestion. The other actions are appropriate for managing a patient with
signs of volume overload and potential cardiac involvement.
7. The nurse is caring for a patient in the emergency department (ED) with massive
trauma and possible spinal cord injury. Which of the following findings by the nurse
will help confirm a diagnosis of neurogenic shock?
A. Cool, clammy skin
B. Inspiratory crackles
C. Apical heart rate 48 beats/minute
,D. Temperature 38.4°C (101.1°F)
Answer: C
Explanation: Neurogenic shock, resulting from spinal cord injury, is characterized by
hypotension and bradycardia due to unopposed parasympathetic activity. Cool, clammy skin
is typical of hypovolemic or cardiogenic shock, crackles suggest pulmonary edema, and fever
is not a specific sign of neurogenic shock.
8. The nurse is caring for a patient in noncardiogenic shock who is cool, clammy and
whose hemodynamic monitoring indicates a high systemic vascular resistance (SVR).
Which of the following actions should the nurse anticipate implementing?
A. Increase the rate for the prescribed dopamine infusion.
B. Decrease the rate for the prescribed nitroglycerin infusion.
C. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion.
D. Increase the rate for the prescribed sodium nitroprusside infusion.
Answer: D
Explanation: A high SVR indicates excessive vasoconstriction. Sodium nitroprusside is an
arterial vasodilator that will decrease SVR and afterload, improving cardiac output.
Increasing dopamine would further increase SVR, and adjustments to nitroglycerin or D5W
would not directly address the high SVR.
9. After receiving 1000 mL of normal saline, the central venous pressure for a patient
who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. Which
of the following prescribed medications should the nurse administer?
A. Nitroglycerin
B. Drotrecogin-α
C. Norepinephrine
D. Sodium nitroprusside
Answer: C
Explanation: After inadequate response to fluid resuscitation, vasopressor drugs like
norepinephrine are administered to increase systemic vascular resistance (SVR) and improve
blood pressure and tissue perfusion. Nitroglycerin and nitroprusside are vasodilators and
would worsen hypotension. Drotrecogin-α addresses inflammation but does not directly raise
blood pressure.
10. The nurse is caring for a patient with septic shock who has a BP of 70/46 mm Hg,
pulse 136, respirations 32, temperature 40°C (104°F), and blood glucose 13.7 mmol/L.
Which of the following prescribed interventions will the nurse implement first?
A. Give normal saline IV at 500 mL/hour.
B. Infuse drotrecogin-α 24 mcg/kg.
C. Start insulin drip to maintain blood glucose at 11–15 mmol/L.
D. Titrate norepinephrine to keep mean arterial pressure (MAP) at 65–70 mm Hg.
Answer: A
Explanation: The initial management of septic shock focuses on aggressive fluid
resuscitation to correct intravascular volume depletion and low systemic vascular resistance.
, Administering normal saline rapidly is the first priority to support blood pressure and organ
perfusion before initiating vasopressors or other specific therapies.
11. The nurse is caring for a patient who has septic shock. Which of the following
assessment findings is most important for the nurse to report to the health care
provider?
A. BP 92/56 mm Hg
B. Skin cool and clammy
C. Apical pulse 118 beats/minute
D. Arterial oxygen saturation 91%
Answer: B
Explanation: Early septic shock is typically characterized by warm, flushed skin due to
vasodilation. The development of cool, clammy skin indicates a worsening state, signaling
progression to a more severe stage of shock with poor perfusion and compensatory
vasoconstriction.
12. The nurse is caring for a patient who is receiving vasopressin to treat septic shock.
Which of the following assessments is most important for the nurse to communicate to
the health care provider?
A. The patient's heart rate is 108 beats/minute.
B. The patient is complaining of chest pain.
C. The patient's peripheral pulses are weak.
D. The patient's urine output is 15 mL/hour.
Answer: B
Explanation: Vasopressin is a potent vasoconstrictor and can cause coronary artery
vasoconstriction, potentially leading to myocardial ischemia. Chest pain is a critical finding
that must be reported immediately as it could indicate a serious adverse effect of the
medication. The other findings are consistent with septic shock itself.
13. Which of the following assessments should the nurse make to evaluate the
effectiveness of omeprazole administration to a patient with systemic inflammatory
response syndrome (SIRS)?
A. Auscultate bowel sounds.
B. Ask the patient about nausea.
C. Monitor stools for occult blood.
D. Check for abdominal distention.
Answer: C
Explanation: Omeprazole is a proton pump inhibitor given to reduce the risk of stress ulcers
in critically ill patients. The most direct way to evaluate its effectiveness is to monitor for the
absence of gastrointestinal bleeding, which is detected by checking stools for occult blood.
14. The nurse is caring for a patient in pulmonary edema as result of cardiogenic shock
has the following vital signs: BP 86/50, pulse 126, respirations 30. Which of the
following actions should the nurse anticipate implementing?
A. Infusion of 5% human albumin
