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Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
1. When caring for a group of clients, the nurse observes which of the following clients for
signs and symptoms of hemorrhagic shock?
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
2. The nurse is caring for a client with papillary muscle rupture. When assessing the
client, the nurse is alert to the development of symptoms related to _________ shock?
1.
2.
3.
4.
Cardiogenic
Anaphylactic
Neurogenic
Septic
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
3. The nurse is caring for a client with endocarditis who is receiving penicillin. The nurse
should be particularly attentive to recognize early symptoms of which of the following
types of shock?
1.
2.
3.
4.
Anaphylactic
Cardiogenic
Hypovolemic
Septic
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
4. When caring for a client in shock, the nurse recognizes that consequences of decreased
blood flow to the kidney will result in:
1.
2.
3.
4.
Azotemia.
Elevated ammonia level.
Hypokalemia.
Hyperglycemia.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
5. The nurse is caring for a client who has developed septic shock related to cancer
chemotherapy. The nurse recognizes changes in mental status most likely result from:
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
6. The nurse is evaluating acidbase status in a client with septic shock. Which of the
following alterations is anticipated?
1.
2.
3.
4.
HCO3 of 10 mEq/L
pH of 7.46
pCO2 of 35 mm HG
pO2 of 77 mm HG
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
7. The family of a client in shock asks why the clients hands are cold. The nurses best
response is which of the following?
1. Blood vessels constrict in shock, which takes the blood away from hands and
feet.
2. We keep the intensive care unit cool to reduce clients metabolic rate.
3. Your family member has developed a fever and chills.
4. This happens frequently to clients in shock states.
Correct Answer: Blood vessels constrict in shock, which takes the blood away from
hands and feet.
Rationale: Vasoconstriction results from catecholamine release, which is a compensatory
mechanism in shock. Cooling measures are used in shock for fever; the ICU is not
purposefully chilled. There is no indication that the client has developed fever and chills.
Stating that cold hands happen frequently does not answer the family members question.
Cognitive Level: Application
Nursing Process: Implementation
Physiological Integrity
Client Need:
LO: 3
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
8. The nurse anticipates that catecholamine release in shock may result in which of the
following?
1.
2.
3.
4.
Hyperglycemia
Bradycardia
Pinpoint pupils
Thirst
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
9. When assessing a client in shock who takes a beta adrenergic blocker, the nurse
recognizes that which of the following responses to shock may be altered?
1.
2.
3.
4.
Tachycardia
Hypotension
Bowel sound
Cyanosis
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
10. The nurse is evaluating the clients in an intensive care unit for risk for sepsis and
septic shock. Clients at risk for sepsis include the client:
Select all that apply.
1.
2.
3.
4.
5.
Correct Answer:
1. From a nursing home with a stage 4 pressure ulcer.
2. With rheumatoid arthritis taking methotrexate.
3. With aplastic anemia.
Rationale: From a nursing home with stage 4 pressure ulcer. Breaches in skin
integrity such as pressure ulcers are risks for sepsis and septic shock. With rheumatoid
arthritis taking methotrexate. Clients such as those taking methotrexate for
chemotherapy or immune modulation are at risk for sepsis and septic shock. With
aplastic anemia. Aplastic anemia results in suppression of all cellular elements of the
bone marrow, including WBCs, which puts the client at risk for infection and sepsis.
With blunt trauma spinal cord injury. Blunt spinal cord injury may lead to spinal or
neurogenic shock. With ruptured viscus vomiting bright red blood. Fluid-volume
deficit secondary to hematemesis may lead to hypovolemic shock.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
11. When caring for a group of critically ill clients, the nurse recognizes that which of the
following patients has risk for increased mortality from sepsis?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
12. The nurse is caring for a group of clients in a critical care unit. Which of the
following clients does the nurse identify as at risk for hypovolemic shock?
Select all that apply.
1.
2.
3.
4.
5.
Correct Answer:
1. Client with ruptured abdominal aortic aneurysm
2. Client with cirrhosis, ascites, and anasarca
3. Client in a multivehicle collision
Rationale: Client with ruptured abdominal aortic aneurysm. Clients at risk for
hypovolemic shock include those with hemorrhage and GI bleeding. Client with
cirrhosis, ascites, and anasarca. Clients at risk for hypovolemic shock include those
with hemorrhage, GI bleeding, third spacing, and unreplaced fluid loss. Client in a
multivehicle collision. Clients at risk for hypovolemic shock include those with
abdominal injury or trauma. Client sustaining a myocardial infarction. A myocardial
infarction may lead to cardiogenic, not hypovolemic, shock. Client with systemic lupus
erythematosus. A client treated for lupus typically takes immunosuppressing drugs such
as corticosteroids, placing the client at risk for septic shock.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
13. The nurse is caring for an 80-year-old client with septic shock admitted from a
nursing home earlier today. Which of the following should the nurse consider the most
likely source of the sepsis?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
14. When caring for a client with suspected cardiogenic shock, which of the following
would be most helpful in confirming the underlying cause?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
15. When caring for a patient who was stabbed in the abdomen, the nurse recognizes that
2 liters of fluid given over the last hour have been ineffective when the patient displays
which of the following?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
16. When admitting a client with septic shock, the nurse focuses on which of the
following potential causes in the patients history?
1.
2.
3.
4.
Rationale: The client who has received an organ transplant must take immunosuppressant
drugs for the life of the transplant, which places the individual at risk for sepsis. A client
who has recovered from cholecystectomy, kidney stones, or MI is not at risk for sepsis.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
17. In order to protect the airway in a client with a Glasgow Coma Scale score of 3, the
nurse collaborates with the health care team to assist with which of the following?
1.
2.
3.
4.
Endotracheal intubation
Assessment of bowel sounds
Monitoring oxygen saturation
Questioning the client regarding difficulty breathing
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
18. When caring for the client in septic shock, the nurse recognizes fluid replacement is
inadequate when which of the following is noted?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
20. The nurse is caring for a client with septic shock. Which of the following findings is
present in septic shock?
1.
2.
3.
4.
Correct Answer: Patient with infection, blood pressure 84/52 after 4 liters of saline
Rationale: By definition, septic shock exists when sepsis is refractory to fluid
resuscitation. A burn injury with fever does not meet the criteria for severe sepsis. A high
WBC count and fever may be present in an uncomplicated infection. Respiratory failure
secondary to pneumonia does not indicate presence of severe sepsis with shock.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 7
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
21. When caring for a client with sepsis, the nurse recognizes that which of the following
indicates a progression to severe sepsis?
Select all that apply.
1.
2.
3.
4.
5.
Correct Answer:
1. Client requires intubation and mechanical ventilation for respiratory failure
2. Blood pressure of 80/42 after 4 liters of fluid have been given
3. Hematuria, epistaxis, and oozing from central venous catheter site
Rationale: Client requires intubation and mechanical ventilation for respiratory
failure. Severe sepsis is defined as the presence SIRS with hypotension/shock, a
confirmed infection, and single or multiple organ failure. Inability to manage
maintenance respiratory functions is consistent with a worsening condition. Blood
pressure of 80/42 after 4 liters of fluid have been given. Continuing hypotension after
the administration of treatment indicates a continuation of responses. Hematuria,
epistaxis, and oozing from central venous catheter site. Coagulopathy may be a
manifestation of worsening sepsis. WBC count of 4000 cells/cubic millimeter. A WBC
count of 4000 is normal. Urine output of 40 to 60 milliliters per hour. Urine output of
40 to 60 ml/hour (or 0.5 ml/kg/hour) is normal.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 7
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
21. The nurse is reviewing the diagnostic tests for a client with an infection. Which of the
following indicates the presence of sepsis?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
22. The nurse plans to administer fluid to a client with SIRS and hypotension. Which of
the following orders should the nurse anticipate to prevent progression of shock?
1.
2.
3.
4.
Correct Answer: Administer 1000 ml of lactated ringers over the next 2 hours.
Rationale: Isotonic solutions, such as normal saline or lactated ringers, should be
administered at a rate of 20 ml/kg/hr and increased to maintain urine output of 0.5
ml/kg/hr. D5 normal saline is a slightly hypertonic fluid; the rate of infusion is too low
for patients in shock. Three percent saline is hypertonic. D5W is a hypotonic solution.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 8
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
23. The critical care nurse is delivering a peer lecture on guidelines for the management
of SIRS and severe sepsis. Current evidence suggests which of the following will
improve outcome in septic shock?
1.
2.
3.
4.
Correct Answer: Maintain blood glucose between 110 and 134 mg/dL
Rationale: Current evidence indicates that maintaining blood glucose <150 mg/dL
improves lipid levels and has anti-inflammatory and anticoagulant properties, improving
chances of survival. Antibiotic therapy should be initiated within the first hour of
identifying sepsis. Mechanical ventilation with tidal volumes of 4 to 6 liters/kg of normal
body weight improves outcome. Bicarbonate is not routinely used for acidosis.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 8
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
24. When caring for the client in septic shock, the nurse recognizes that current evidence
supports use of which of the following interventions to improve outcome?
1.
2.
3.
4.
Rationale: Current evidence suggests that maintaining mechanical ventilation with lowerthan-traditional tidal volumes of 4 to 6 ml/kg results in improved outcome. Vasopressin is
indicated when other pressors have failed to restore blood pressure. Fluid restriction is
indicated in cardiogenic shock. Positioning the client flat may be necessary to maintain
MAP.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 8
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
25. Which of the following interventions will reduce metabolic demands in a client with
multiple organ dysfunction syndrome?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
26. The nurse is caring for a client with septic shock and MODS. The clients family
member tearfully tells the nurse, The doctor said my mothers organs are shutting down.
How did that happen? Which of the following is the best response?
1.
2.
3.
4.
Correct Answer: Deprivation of oxygen during shock causes organs to fail to function
properly.
Rationale: The cascade of events in shock states results in inadequate tissue perfusion and
hypoxia leading to organ failure. Infection does not strike each organ; rather, an
inflammatory process begins a cascade of events impairing tissue perfusion that causes
organs to fail. Fever may cause brain damage if exceedingly high and increase metabolic
demand, increasing oxygen demand, but it is not the primary reason for MODS. The
stress response is activated as a compensatory mechanism; however, it is not the primary
reason for MODS.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 9
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
27. When planning care for a client with MODS secondary to septic shock, the nurse
suggests which of the following to the provider, as evidence shows a reduction in
mortality?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
28. Which of the following is the priority for a client with MODS and adult respiratory
distress syndrome (ARDS)?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
29. The nurse is caring for a client with MODS secondary to septic shock whose urine
output was 10 ml for the last 2 hours. Temperature is 97 degrees, pulse is 124 and
thready, and BP is 88/48. Which of the following orders is the priority at this time?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
30. Which of the following should take priority in a patient with MODS secondary to
severe sepsis?
1.
2.
3.
4.
pO2 of 54 mmHg
WBC count of 28,000 cell/cubic mm
Serum lactate level is 2 mmol/L
Blood glucose of 245 mg/dL
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.