A 45-year-old patient is admitted to the emergency department with a diagnosis of septic shock. The nurse observes the patient’s vital signs and notes a heart rate of 120 beats per minute, respiratory rate of 28 breaths per minute, blood pressure of 80/50 mm Hg, and cool, clammy skin. What is the priority nursing intervention?
A) Administer a bolus of hypertonic saline.
B) Administer an antipyretic to reduce fever.
C) Start intravenous antibiotics immediately.
D) Initiate passive range of motion exercises.
E) Apply a heating pad to the extremities.
Rationale: Septic shock is characterized by a systemic response to infection leading to hypotension and organ dysfunction. The priority intervention is to administer intravenous antibiotics promptly to target the underlying infection and prevent further deterioration. Time is crucial in septic shock management, and early antibiotic therapy has been shown to improve outcomes by addressing the source of infection.
A patient in septic shock is receiving fluid resuscitation with crystalloid solutions. The nurse assesses the patient’s central venous pressure (CVP) as an indicator of fluid status. What CVP value is indicative of adequate fluid resuscitation in septic shock?
A) 2 mm Hg
B) 8 mm Hg
C) 15 mm Hg
D) 20 mm Hg
E) 25 mm Hg
Rationale: Monitoring central venous pressure is essential in managing septic shock and guiding fluid resuscitation. A CVP of 8-12 mm Hg is generally considered indicative of adequate fluid status. Higher values may suggest fluid overload, while lower values may indicate the need for additional fluid administration. Maintaining an appropriate CVP helps optimize tissue perfusion and cardiac output.
POP QUIZ
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Understanding Septic Shock: NCLEX Priority Questions
A nurse is caring for a patient with septic shock who is receiving vasopressor therapy. The patient’s blood pressure has improved, but the nurse notes decreased urine output. What action should the nurse take?
A) Increase the vasopressor infusion rate.
B) Administer a loop diuretic.
C) Document the findings as expected.
D) Hold the vasopressor and notify the healthcare provider.
E) Encourage increased oral fluid intake.
Rationale: While vasopressors are essential in managing septic shock, a decrease in urine output may indicate impaired renal perfusion. Holding the vasopressor and notifying the healthcare provider allows for a reassessment of the patient’s overall condition and consideration of interventions to optimize renal function, such as fluid resuscitation or adjustment of medications. Addressing renal perfusion is crucial for preventing acute kidney injury in septic shock.
Understanding Septic Shock: NCLEX Delegation Questions
A patient in septic shock is experiencing disseminated intravascular coagulation (DIC). The nurse is aware that this condition is characterized by widespread clot formation and subsequent consumption of clotting factors. What laboratory finding is commonly associated with DIC in septic shock?
A) Elevated prothrombin time (PT)
B) Decreased fibrin degradation products (FDP)
C) Normal platelet count
D) Low D-dimer levels
E) Increased fibrinogen levels
Rationale: Disseminated intravascular coagulation in septic shock results in the consumption of clotting factors, leading to an elevated prothrombin time. This indicates impaired blood clotting ability and an increased risk of bleeding. Monitoring PT is crucial in assessing the severity of DIC and guiding appropriate interventions, such as administering clotting factor replacement or anticoagulant therapy.
Understanding Septic Shock: Causes and Symptoms
A patient with septic shock is prescribed a norepinephrine infusion to maintain blood pressure. The nurse is assessing for potential complications related to the administration of this vasopressor. Which complication requires immediate intervention?
A) Bradycardia
B) Hypertension
C) Peripheral cyanosis
D) Extravasation at the infusion site
E) Increased urine output
Rationale: Norepinephrine is a vasopressor that primarily acts to increase blood pressure. However, a potential adverse effect is reflex bradycardia. This occurs due to baroreceptor reflex activation in response to increased blood pressure. Bradycardia can compromise cardiac output and tissue perfusion. Immediate intervention, such as adjusting the vasopressor infusion rate or administering an anticholinergic medication, is necessary to address this complication and maintain hemodynamic stability.
NCLEX Practice Questions: Understanding Septic Shock Causes and Symptoms
A 28-year-old patient presents to the emergency department with sudden-onset difficulty breathing, facial swelling, and hives after receiving an intramuscular injection of penicillin. The nurse suspects anaphylactic shock. What is the immediate priority nursing intervention?
A) Administer an antihistamine.
B) Initiate oxygen therapy.
C) Start intravenous antibiotics.
D) Administer a corticosteroid.
E) Perform a complete blood count (CBC).
Rationale: Anaphylactic shock is a life-threatening hypersensitivity reaction that can lead to respiratory distress. The immediate priority is to ensure adequate oxygenation. Initiating oxygen therapy helps address hypoxia, a common complication in anaphylaxis, and supports respiratory function. While antihistamines and corticosteroids are important components of treatment, ensuring oxygen delivery takes precedence in managing acute respiratory compromise.
NCLEX Questions: Focus on Medications for Septic Shock
A patient in anaphylactic shock has received an epinephrine injection. The nurse should monitor the patient for which potential adverse effect of epinephrine?
A) Hypertension
B) Bradycardia
C) Hyperglycemia
D) Respiratory depression
E) Increased urine output
Rationale: Epinephrine is a key medication in managing anaphylactic shock, acting as a bronchodilator and vasoconstrictor. One potential adverse effect is hypertension due to increased systemic vascular resistance. Monitoring blood pressure is essential to ensure a balance between improving cardiac output and preventing excessive vasoconstriction, which could lead to hypertension and potential complications such as myocardial ischemia.
NCLEX Focus Exploring Septic Shock: Causes and Diagnosis
A nurse is caring for a patient who has experienced anaphylactic shock. The patient is now stable, and the nurse is educating them about preventing future episodes. What instruction is essential for the patient to prevent anaphylactic reactions?
A) Avoiding sunlight exposure
B) Using scented lotions and soaps
C) Wearing tight-fitting clothing
D) Reading food labels for allergens
E) Engaging in intense physical exercise
Rationale: Prevention of anaphylactic reactions involves identifying and avoiding triggers. Reading food labels for potential allergens is crucial, as many anaphylactic reactions are triggered by food allergies. Providing education on allergen identification empowers the patient to make informed choices and minimize the risk of exposure to substances that can lead to anaphylaxis.
NCLEX Review: Septic Shock Treatments
A patient with a history of anaphylactic reactions carries an epinephrine auto-injector. The nurse is teaching the patient how to use the auto-injector. What instruction should the nurse provide regarding the administration of the epinephrine?
A) Administer the injection into the muscle of the thigh.
B) Inject the medication into the upper arm.
C) Use the auto-injector only if respiratory distress occurs.
D) Wait for someone else to administer the medication.
E) Administer the injection into the abdomen.
Rationale: The correct administration site for an epinephrine auto-injector is the muscle of the thigh. This route ensures rapid absorption and onset of action. Waiting for someone else to administer the medication may cause unnecessary delays, and using the auto-injector only if respiratory distress occurs may not address other severe symptoms of anaphylaxis. Proper education on the correct administration site empowers the patient to take prompt action in case of an emergency.
NCLEX Questions Critical Thinking: Septic Shock Symptoms
A 35-year-old patient is brought to the emergency department with symptoms of anaphylactic shock following the ingestion of a seafood dish. The patient is experiencing respiratory distress, hypotension, and generalized urticaria. The healthcare team administers an epinephrine injection. What is the primary action of epinephrine in managing anaphylactic shock?
A) Increasing bronchoconstriction
B) Decreasing heart rate
C) Dilating blood vessels
D) Reducing systemic vascular resistance
E) Inhibiting histamine release
Rationale: Epinephrine acts as a potent vasoconstrictor and bronchodilator. In the context of anaphylactic shock, its primary action is to dilate blood vessels, particularly in the peripheral circulation. This helps counteract the severe vasodilation and increased vascular permeability associated with anaphylaxis, leading to improved blood pressure and tissue perfusion. While it also has bronchodilator effects and inhibits histamine release, the immediate priority in anaphylactic shock is addressing hypotension through vasoconstriction.
