Chapter 18 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 18

Question 1

Type: MCSA

The nurse is identifying interventions to prevent the development of sepsis in an older patient because:

1. Mortality rates from sepsis are 70% worldwide.

2. If managed early and aggressively, the majority of patients with sepsis may be managed outside of the ICU environment.

3. The guidelines provided by the Surviving Sepsis Campaign are expected to decrease the incidence of sepsis.

4. Sepsis rates rise sharply with age.

Correct Answer: 4

Rationale 1: Current mortality rates for sepsis are estimated to range between 23% to 46% depending on the patients age, underlying condition, and site of infection.

Rationale 2: Seventy percent of patients with sepsis are managed in the ICU or other specialty critical care area.

Rationale 3: The Surviving Sepsis program aims to increase awareness, understanding, and knowledge; change perceptions and behavior; increase the pace of change in patterns of care; influence public policy; define standards of care in severe sepsis; and reduce the mortality associated with sepsis.

Rationale 4: Because sepsis affects the elderly disproportionately, more than half of all annual costs in the United States$8.7 billionwere spent on care of septic patients 65 years or older.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-1: Differentiate between systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.

Question 2

Type: MCSA

While caring for an older patient, the nurse is aware that the two most common sources of infection that can lead to sepsis in this patient include:

1. Pneumonia and urinary tract infections

2. Skin infections and diabetes

3. Surgical incisions and abdominal wounds

4. Traumatic wounds and abdominal surgeries

Correct Answer: 1

Rationale 1: The most common source of sepsis stems from urinary tract infections and pneumonia. Among older patients, the most common source of infection is the urinary tract. The second most common source, the lungs, accounts for 35% of sepsis cases.

Rationale 2: Skin and soft tissue account only for 7% of sepsis. Diabetes increases the patients risk for developing sepsis.

Rationale 3: Other sources account only for 8% of sepsis cases.

Rationale 4: Other sources account only for 8% of sepsis cases.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-2: Describe evidence based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections.

Question 3

Type: MCSA

Which evidence based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation?

1. Aseptic technique when performing oral hygiene

2. Administration of an H2 antagonist to prevent peptic ulcers

3. Elevation of the head of the bed to 15 degrees to prevent aspiration

4. Changing the ventilator circuit daily

Correct Answer: 2

Rationale 1: Oral hygiene is a clean, rather than a sterile, procedure.

Rationale 2: One of the evidence based practices used to prevent ventilator-associated pneumonia includes the use of an H2 antagonist to prevent peptic ulcers.

Rationale 3: The head of the bed should be elevated at least 30 degrees.

Rationale 4: The ventilator circuit is changed weekly.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-2: Describe evidence based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections.

Question 4

Type: MCSA

Which statement accurately describes the purpose of sedation vacation for a patient to prevent ventilator-associated pneumonia?

1. The vacation from sedation relieves stress, which decreases the chance of infection.

2. During sedation vacation the patient has a chance to take deep breaths and improve ventilation while more awake.

3. The patients own tidal volume and respiratory rate can be evaluated during sedation vacation.

4. New data show that sedation vacation is no longer recommended because there is concern about the safety of interrupting sedation.

Correct Answer: 3

Rationale 1: Sedation vacation is necessary to accurately measure tidal volume and respiratory rate, which are criteria to assess readiness to extubate.

Rationale 2: This is not the purpose of a sedation vacation.

Rationale 3: Mechanical ventilation is discontinued sooner when close attention is given to measuring tidal volume and respiratory rate, which occurs during a sedation vacation. Evidence indicates that appropriate use of daily interruption of sedation to determine readiness to wean decreases the patients time on a ventilator.

Rationale 4: There is concern among some nurses about the safety of interrupting sedation; therefore, most institutions have specific policies outlining for whom and when sedation interruption should be attempted.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-2: Describe evidence based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections.

Question 5

Type: MCSA

Why is the nurse implementing actions to prevent the onset of catheter-related infections in a patient receiving care in the intensive care unit?

1. Statistics report that as many as one in five individuals who develop a catheter-related infection die from it.

2. Nosocomial catheter-related infections prolong hospitalization by an average of 4 days.

3. The increased cost of care due to the development of a blood-borne infection averages between $1,700 and $17,000.

4. Central venous catheters have about the same rate of infection as peripherally inserted catheters.

Correct Answer: 1

Rationale 1: Mortality attributable to these infections is between 4% and 20%, so between 500 and 4,000 patients in the United States died annually due to CVC-related bloodstream infections.

Rationale 2: These infections prolong hospitalization by a mean of 7 days.

Rationale 3: These infections prolong hospitalization by a mean of 7 days at a cost of between $3,700 to $29,000.

Rationale 4: The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-2: Describe evidence based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections.

Question 6

Type: MCSA

Which action is a part of the bundle of measures used to prevent nosocomial catheter-related infections?

1. Chlorhexidine is most effective when swabbed starting at the insertion site and moving outward in a circular motion.

2. It is recommended that transparent dressings be changed every 72 hours to prevent growth of bacteria on the skin.

3. Current recommendations support changing IV tubing every 48 hours on patients at risk for catheter-related infections.

4. During insertion of a central line the doctor should wear a cap and mask, sterile gloves, and a gown, and the patient should have a full body drape.

Correct Answer: 4

Rationale 1: Chlorhexidine is used in a scrubbing motion rather than in a circular motion.

Rationale 2: An original central line dressing should be changed after 24 hours and when soiled with blood or fluid. Central line dressings may be changed every 7 days.

Rationale 3: Current recommendations are to change IV tubing every 72 to 96 hours. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused.

Rationale 4: During insertion of a central line the doctor should wear a cap, a mask, sterile gloves, and a gown. The patient should have a full body drape. These measures prevent catheter-related sepsis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-2: Describe evidence based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections.

Question 7

Type: MCSA

The nurse is evaluating a patient for the presence of systemic inflammatory response syndrome (SIRS). Which assessment data indicates the presence of SIRS?

1. Temperature 36.4C, respiratory rate 22, pulse rate 112, and PaCO2 34

2. Temperature 38.4C, respiratory rate 23, pulse rate 92, and PaCO2 31

3. Temperature 37.2C, respiratory rate 24, pulse rate 102, and PaCO2 44

4. Temperature 38.8C, respiratory rate 25, pulse rate 88, and PaCO2 48

Correct Answer: 2

Rationale 1: This data does not support the finding of SIRS.

Rationale 2: The definition of SIRS includes temperature 38 degrees centigrade, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute with a PaCO2 less than 32 torr.

Rationale 3: This data does not support the finding of SIRS.

Rationale 4: This data does not support the finding of SIRS.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18-3: Perform a nursing assessment of the patient with SIRS and severe sepsis.

Question 8

Type: MCSA

The nurse is assessing a patient for severe sepsis. Which finding indicates the patient is developing this health problem?

1. Decreased capillary filling and mottling

2. Fever and decreased urine output

3. Hypotension and lactic acidosis

4. Increased glomerular filtration rate and increased D-dimer levels

Correct Answer: 3

Rationale 1: Decreased capillary filling and mottling are both related to sepsis instead of severe sepsis.

Rationale 2: Fever and decreased urine output are both related to sepsis instead of severe sepsis.

Rationale 3: The best description of severe sepsis is hypotension and lactic acidosis. These signs also represent altered cellular metabolism, which results in organ dysfunction.

Rationale 4: In severe sepsis a decreased, rather than increased, glomerular filtration rate would be expected.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-1: Differentiate between systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.

Question 9

Type: MCSA

Which hemodynamic parameters would the nurse expect to see in the patient with septic shock?

1. Central venous pressure (CVP) 4 mm Hg, pulmonary artery pressure (PAP) 30/15 mm Hg, and systemic vascular resistance (SVR) 1,200 dynes/sec/cm-5

2. Central venous pressure (CVP) 8 mm Hg, pulmonary artery pressure (PAP) 26/10 mm Hg, and systemic vascular resistance (SVR) 1,000 dynes/sec/cm-5

3. Central venous pressure (CVP) 2 mm Hg, pulmonary artery pressure (PAP) 20/8 mm Hg, and systemic vascular resistance (SVR) 800 dynes/sec/cm-5

4. Central venous pressure (CVP) 6 mm Hg, pulmonary artery pressure (PAP) 40/20 mm Hg, and systemic vascular resistance (SVR) 700 dynes/sec/cm-5

Correct Answer: 3

Rationale 1: These parameters are outside those expected for septic shock.

Rationale 2: These parameters are outside those expected for septic shock.

Rationale 3: Septic shock is a form of distributive shock. Central venous pressure would be low, pulmonary artery pressure would be low, and systemic vascular resistance would be low.

Rationale 4: These parameters are outside those expected for septic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18-3: Perform a nursing assessment of the patient with SIRS and severe sepsis.

Question 10

Type: MCSA

The nurse is assessing a patient for septic shock. Which statement best describes this health problem?

1. Sepsis with hypotension that does not correct itself when a fluid challenge is administered

2. Sepsis with hypotension accompanied by decreased protein C levels and coagulation abnormalities

3. Sepsis with hypotension accompanied by increased creatinine and absent bowel sounds

4. Sepsis with hypotension accompanied by altered mental status and lactic acidosis

Correct Answer: 1

Rationale 1: Septic shock is defined by the presence of sepsis plus refractory hypotension.

Rationale 2: In septic shock, protein C would be elevated as a result of fibrinolysis.

Rationale 3: This describes severe sepsis with signs of organ failure but not specifically septic shock.

Rationale 4: This describes severe sepsis with signs of organ failure but not specifically septic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-1: Differentiate between systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.

Question 11

Type: MCSA

Which statement will the nurse use to explain why serum lactate is elevated in a patient with sepsis? It is caused by:

1. Increased systemic inflammation

2. The endogenous by-products of bacterial contamination

3. Anaerobic cellular metabolism

4. Greatly accelerated coagulation

Correct Answer: 3

Rationale 1: This is not related to the elevation of serum lactate in sepsis.

Rationale 2: This is not related to the elevation of serum lactate in sepsis.

Rationale 3: Lactic acid is produced as a by-product of anaerobic cellular metabolism.

Rationale 4: This is not related to the elevation of serum lactate in sepsis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4: Discuss the elements of the sepsis resuscitation bundle.

Question 12

Type: MCSA

What will the nurse do when administering antibiotics to a patient with sepsis?

1. Antibiotics should be administered as soon as the patient has received a fluid bolus.

2. Antibiotics should always be administered after blood cultures are obtained.

3. Administer the antibiotic with the shortest administration time first so that all antibiotics are administered quickly.

4. Wait for the results of liver and renal function tests before beginning antibiotic therapy.

Correct Answer: 2

Rationale 1: Antibiotics should be administered as soon as possible to decrease mortality.

Rationale 2: Blood cultures must be obtained prior to the administration of antibiotics in order to isolate the infecting organism successfully.

Rationale 3: The broad spectrum antibiotic should be administered first.

Rationale 4: Medication dosage adjustments are made to compensate for liver and kidney dysfunction rather than limiting the choices of antibiotics.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4: Discuss the elements of the sepsis resuscitation bundle.

Question 13

Type: MCSA

The goal of antibiotic therapy in a patient with sepsis is to narrow the therapy to one narrow-spectrum antibiotic. What purpose does this goal serve in the patients care and how does it aid in the prevention of antibiotic resistance?

1. The use of one antibiotic ensures that the prescribed dose will result in serum concentrations that are clinically effective.

2. The use of one antibiotic has been shown to cause less organ dysfunction.

3. The use of one antibiotic reduces mortality in patients with sepsis.

4. The use of one antibiotic limits the cost to the patient.

Correct Answer: 4

Rationale 1: Patients with sepsis have abnormal renal and hepatic function; the pharmacist should be consulted to ensure that the prescribed dose results in serum concentrations that are both clinically effective and minimally toxic.

Rationale 2: The goal is to narrow therapy once culture results identify the infecting organism. This has several benefits, including decreased cost, prevention of the development of resistance, and reduced toxicity.

Rationale 3: This is not a true statement.

Rationale 4: One antibiotic can ultimately reduce the patients costs but that is not the only purpose of this goal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-4: Discuss the elements of the sepsis resuscitation bundle.

Question 14

Type: MCSA

The best description of the overall goal of providing fluid resuscitation and vasopressors to a patient in septic shock is to:

1. Increase the systolic arterial pressure.

2. Provide adequate vasoconstriction.

3. Increase tissue perfusion.

4. Increase the metabolic rate.

Correct Answer: 3

Rationale 1: The goal is to maintain an adequate mean arterial pressure (increase perfusion) rather than to specifically increase systolic pressure.

Rationale 2: The goal is to maintain an adequate mean arterial pressure (increase perfusion) rather than to specifically increase systolic pressure.

Rationale 3: The overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to increase tissue perfusion. Vasopressors are used if the initial fluid bolus fails to bring the mean arterial pressure over 80 mm Hg.

Rationale 4: The goal is to maintain an adequate mean arterial pressure (increase perfusion) rather than to specifically increase systolic pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-4: Discuss the elements of the sepsis resuscitation bundle.

Question 15

Type: MCSA

Why will the nurse monitor the SVO2 in a patient with septic shock?

1. A SvO2 of 65% shows that the oxygen demand of tissues exceeds the oxygen supply.

2. A SvO2 of 95% or above shows normal oxygen supply and demand.

3. A SvO2 of 70% is adequate to deliver oxygen to body organs and tissues.

4. A decrease in the SvO2 shows that more oxygen is returning to the lungs before being metabolized.

Correct Answer: 3

Rationale 1: This value is normal and indicates a balance.

Rationale 2: A SvO2 of 95% is high, indicating that the cardiac output is insufficient to meet the oxygen demands.

Rationale 3: The SvO2 is a measure of systemic oxygen utilization and an indirect measure of perfusion. The normal SvO2 is 60% to 80%. A SvO2 of 70% is normal, indicating adequate oxygen delivery to body organs and tissues.

Rationale 4: A decline in SvO2 indicates that the demand of the tissues exceeds the oxygen delivery.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18-4: Discuss the elements of the sepsis resuscitation bundle.

Question 16

Type: MCSA

Dobutamine is often used in the treatment of sepsis at a moderate or high dose to improve a patients hemodynamics. The nurse knows that this medication is used because:

1. It decreases systemic vascular resistance and increases perfusion to organs.

2. It has no effect on systemic vascular resistance but improves oxygenation.

3. It decreases the heart rate and increases oxygen delivery to the tissues.

4. It increases systemic vascular resistance and improves hemodynamics.

Correct Answer: 1

Rationale 1: Dobutamine is an inotrope that has beta-adrenergic effects. The expected outcome is to increase contractility and to vasodilate, which increases microcirculation or blood flow and organ perfusion.

Rationale 2: Vasodilatation decreases systemic vascular resistance.

Rationale 3: A side effect of dobutamine infusion is sinus tachycardia.

Rationale 4: Dobutamine decreases systemic vascular resistance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-5: Compare and contrast the use of three vasoactive medications in the management of septic shock.

Question 17

Type: MCSA

The nurse, implementing the sepsis management bundle for a patient in the intensive care unit, is aware of which information about this bundle?

1. When all elements of the sepsis management bundle are used, survival is prolonged.

2. The sepsis management bundle has not received uniform support.

3. The purpose of the sepsis management bundle is to improve the patients hemodynamics within 4 hours.

4. The Surviving Sepsis Campaign recommends universal use of each of the elements of the sepsis management bundle to decrease mortality.

Correct Answer: 2

Rationale 1: Evidence has not consistently shown survival.

Rationale 2: The sepsis management bundle has not received uniform support because the elements have not been shown to increase survival or to decrease mortality.

Rationale 3: There is no evidence for improvement in 4 hours.

Rationale 4: The surviving sepsis campaign has recommended that each of the elements be assessed and, if appropriate, the interventions be instituted.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6: Describe the elements in the sepsis management bundle.

Question 18

Type: MCSA

Steroids may be prescribed to a patient in septic shock. For what additional interventions would the nurse plan when providing this medication?

1. There is a slower reversal of sepsis when steroids are given.

2. There is a risk of superinfection when steroids are given.

3. Vasopressor therapy can often be reduced when steroids are given.

4. Immunosuppression is reduced when steroids are given.

Correct Answer: 2

Rationale 1: The use of steroids does not cause a slower reversal of sepsis.

Rationale 2: The use of steroids in the treatment of sepsis can lead to more problems with superinfection.

Rationale 3: Steroids may be used to improve vasomotor tone.

Rationale 4: Immunosuppression is a side effect of corticosteroid use.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-6: Describe the elements in the sepsis management bundle.

Question 19

Type: MCSA

What will the nurse include in the management plan for a patient with sepsis?

1. Use high tidal volumes on the ventilator to prevent adult respiratory distress syndrome (ARDS).

2. Assess capillary blood glucose and prevent hyperglycemia.

3. Stabilize and debride an infected wound after administering antibiotics for 24 hours.

4. Avoid CT and MRI scans until the patient is stable.

Correct Answer: 2

Rationale 1: High tidal volumes should be avoided in the presence of ARDS and do not prevent its development.

Rationale 2: The blood glucose should be maintained between 80 and 150 mg/dL.

Rationale 3: Sources of infection should be removed as soon as possible.

Rationale 4: CT and MRI scans are often helpful in identifying causes of sepsis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-6: Describe the elements in the sepsis management bundle.

Question 20

Type: MCSA

Which action should the nurse implement to help reduce the fever in a patient with sepsis?

1. A cooling blanket is often considered when the patients temperature reaches 103F.

2. Shivering should be avoided because it causes a decreased metabolic rate.

3. Prevent shivering by keeping the patients hands and feet on the cooling blanket.

4. Sedation should be avoided during the use of the cooling blanket because it masks potential shivering.

Correct Answer: 1

Rationale 1: Exogenous cooling is recommended when a patients temperature reaches 103F.

Rationale 2: Shivering increases rather than decreases the metabolic rate.

Rationale 3: The hands and feet should be kept off the cooling blanket to prevent shivering.

Rationale 4: The use of sedation is preferable because it decreases shivering and helps to decrease the temperature.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-7: Evaluate methods used to reduce fever in a febrile patient.

Question 21

Type: MCSA

In order to meet the patients nutritional needs during a critical illness with sepsis, the nurse knows that:

1. TPN is the preferable means to administer nutrition.

2. Nutritional needs are usually addressed after 72 hours in order to conserve energy expenditure.

3. Enteral feedings are often avoided because hyperglycemia often results from feedings.

4. Enteral feedings prevent translocation of bacteria from the gastrointestinal tract.

Correct Answer: 4

Rationale 1: TPN increases the chances of hyperglycemia as well as bloodstream infections due to the high dextrose content.

Rationale 2: Nutritional needs should be met early to promote healing, ideally before 72 hours from the time of admission.

Rationale 3: Enteral feedings are the preferred method of meeting nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract.

Rationale 4: Enteral feedings are the preferred method of meeting nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-7: Evaluate methods used to reduce fever in a febrile patient.

Question 22

Type: MCSA

Which statement best describes the pathophysiology of multiple organ dysfunction syndrome (MODS) in a patient with sepsis?

1. The primary cause of MODS is decreased blood pressure.

2. Endothelial dysfunction is a primary cause of MODS.

3. Increased microvascular bleeding causes MODS.

4. Circulating pathogens cause destruction of organs, resulting in MODS.

Correct Answer: 2

Rationale 1: Endothelial dysfunction occurs as a result of damage to the endothelial layers. MODS results because of a variety of factors. Vasoactive and procoagulant mediators are released. Vascular permeability and shunting occur.

Rationale 2: Endothelial dysfunction is a primary cause of MODS.

Rationale 3: Microvascular bleeding is a result, not a cause, of MODS.

Rationale 4: Circulating pathogens does not cause destruction of organs leading to MODS.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-8: Explain the process of disseminated intravascular coagulation.

Question 23

Type: MCSA

The nurse is evaluating a patient with sepsis for the development of disseminated intravascular coagulation (DIC). What is a sign that the patient may have developed this complication?

1. Ecchymoses of the gums or skin

2. Resistance when flushing a capped port of a central venous catheter

3. A reduction in the D-dimer

4. Increased fibrinogen levels

Correct Answer: 1

Rationale 1: Ecchymoses of the gums or skin is a sign that the patient has developed DIC.

Rationale 2: The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter.

Rationale 3: The D-dimer will be increased due to fibrinolysis.

Rationale 4: Fibrinogen and platelets will be decreased as they are used in the clotting cascade.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18-8: Explain the process of disseminated intravascular coagulation.

Question 24

Type: MCMA

A patient in the intensive care unit has been diagnosed with systemic inflammatory response syndrome (SIRS). What additional findings indicate the patient is becoming septic?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Blood pressure 70/48 mm Hg

2. Urine output 10 mL/hr

3. Blood glucose level 185 mg/dL

4. Heart rate 88

5. Respiratory rate 16

Correct Answer: 1,2,3

Rationale 1: Hypotension is an indication of sepsis.

Rationale 2: Decreased urine output is an indication of sepsis.

Rationale 3: Plasma glucose greater than 120 mg/dL is an indication of sepsis.

Rationale 4: A heart of rate of 88 is within normal limits and does not indicate sepsis.

Rationale 5: A respiratory rate of 16 is within normal limits and does not indicate sepsis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-1: Differentiate between systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.

Question 25

Type: MCMA

The nurse is preparing a patient for surgery to repair an abdominal aortic aneurysm. Which interventions would reduce the patients risk of developing a surgical site infection?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer prescribed antibiotic 1 hour before the surgery begins.

2. Discontinue intravenous antibiotics 24 hours after the surgery.

3. Shave abdominal region before the surgery.

4. Remove excess hair from abdominal area with an electric clipper.

5. Apply antiembolism stocking prior to surgery.

Correct Answer: 1,2,4

Rationale 1: Providing an appropriate antibiotic no more than 1 hour prior to the surgical incision results in fewer surgical site infections.

Rationale 2: Discontinuing antibiotics 24 hours after surgery results in fewer surgical site infections.

Rationale 3: There is no evidence to recommend removing hair from the surgical site prior to surgery. Shaving should not be performed.

Rationale 4: If hair removal is necessary, it should be removed with the use of an electric clipper.

Rationale 5: The application of antiembolism stocking will not reduce the patients risk of developing a surgical site infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-2: Describe evidence based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections.

Question 26

Type: MCMA

Which assessment findings should cause a nurse to be concerned that a patient is developing severe sepsis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Serum creatinine level 2.0 md/dL

2. Absent bowel sounds

3. Onset of confusion

4. Heart rate 54

5. Blood pressure 148/90 mm Hg

Correct Answer: 1,2,3

Rationale 1: In severe sepsis, renal dysfunction is evidenced by an increase in serum creatinine greater than 0.5 mg/dL.

Rationale 2: Gastrointestinal effects of severe sepsis are evidenced by absent bowel sounds or ileus.

Rationale 3: Neurological dysfunction of severe sepsis is indicated by a sudden change in mental status with possible confusion.

Rationale 4: Tachycardia (not bradycardia) is a cardiovascular effect of severe sepsis.

Rationale 5: Hypotension (not hypertension) is a cardiovascular effect of severe sepsis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-3: Perform a nursing assessment of the patient with SIRS and severe sepsis.

Question 27

Type: MCMA

A patient in the emergency department is demonstrating signs of sepsis. Which interventions will the nurse implement as part of the sepsis resuscitation bundle?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Draw blood for a serum lactate level.

2. Obtain blood cultures.

3. Provide a broad spectrum antibiotic.

4. Administer low dose steroids.

5. Provide insulin for blood glucose level 200 mg/dL.

Correct Answer: 1,2,3

Rationale 1: This is the first element of the sepsis resuscitation bundle.

Rationale 2: This is the second element of the sepsis resuscitation bundle.

Rationale 3: This is the third element of the sepsis resuscitation bundle.

Rationale 4: This is a step of the sepsis management bundle.

Rationale 5: This is a step of the sepsis management bundle.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4: Discuss the elements of the sepsis resuscitation bundle.

Question 28

Type: MCMA

The nurse is preparing an infusion of norepinephrine for a patient in severe septic shock. Why is this medication being used for the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. It will increase the patients MAP.

2. It reverses hypotension when fluid resuscitation was unsuccessful.

3. It increases stroke volume.

4. It increases heart rate.

5. Effects are seen in 5 minutes.

Correct Answer: 1,2

Rationale 1: Norepinephrine usually results in a significant increase in MAP with little change in heart rate or cardiac output.

Rationale 2: It seems to be more effective than dopamine at reversing hypotension in septic shock patients resistant to fluid resuscitation.

Rationale 3: Dopamine increases MAP primarily by increasing stroke volume.

Rationale 4: Dopamine increases MAP primarily by increasing heart rate.

Rationale 5: The effects of norepinephrine are seen in 1 to 2 minutes after administering.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-5: Compare and contrast the use of three vasoactive medications in the management of septic shock.

Question 29

Type: MCMA

The physician has prescribed the sepsis management bundle to be implemented in a patient with severe sepsis. The nurse will prepare to administer which interventions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer steroids as prescribed.

2. Administer human recombinant activated protein C.

3. Administer insulin coverage for blood glucose greater than 150 mg/dL.

4. Administer a fluid challenge.

5. Assist with the insertion of a central line.

Correct Answer: 1,3

Rationale 1: Steroids are a part of the sepsis management bundle.

Rationale 2: The drug has been removed from the market.

Rationale 3: The treatment of elevated blood glucose levels is a part of the sepsis management bundle.

Rationale 4: A fluid challenge is a part of the sepsis resuscitation bundle.

Rationale 5: Central line insertion is a part of the sepsis resuscitation bundle.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6: Describe the elements in the sepsis management bundle.

Question 30

Type: MCMA

A patient with sepsis is experiencing an elevated temperature. Which medications would the nurse prepare to administer to this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Acetaminophen

2. Ibuprofen

3. Aspirin

4. Warfarin sodium

5. Heparin

Correct Answer: 1,2

Rationale 1: Acetaminophen is commonly used to reduce a fever in a patient with sepsis.

Rationale 2: Ibuprofen is used to reduce a fever in a patient with sepsis.

Rationale 3: Aspirin is not used to reduce a fever in a patient with sepsis.

Rationale 4: Warfarin sodium is an anticoagulant and not an antipyretic.

Rationale 5: Heparin is an anticoagulant and not an antipyretic.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-7: Evaluate methods used to reduce fever in a febrile patient.

Question 31

Type: MCMA

While caring for a patient with sepsis, the nurse suspects that disseminated intravascular coagulation is developing. What did the nurse assess in the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Cyanosis of the fingers

2. Patient complains of finger pain

3. Diminished pulses

4. New onset of confusion

5. Urine output 60 mL/hr

Correct Answer: 1,2,3,4

Rationale 1: Occlusion of blood vessels may be seen as cyanosis and/or gangrene, especially of the digits. There may actually be a demarcation line between the viable and necrotic tissue visible on the fingers or toes, and the patient may complain of pain in the digits.

Rationale 2: Occlusion of blood vessels may be seen as cyanosis and the patient may complain of pain in the digits.

Rationale 3: Diminished pulses are an indication of disseminated intravascular coagulation.

Rationale 4: Inadequate perfusion of the brain may present as an altered level of consciousness, especially confusion.

Rationale 5: An increase in urine output is not an indication of disseminated intravascular coagulation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-8: Explain the process of disseminated intravascular coagulation.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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