Free NCLEX-RN Physiological Adaptation questions
22 original Physiological Adaptation questions on alterations in body systems, fluid and electrolyte imbalances, illness management, medical emergencies, in Next Generation NCLEX formats.
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NCLEX-RN Physiological Adaptation questions
- 22 questions
- Physiological Adaptation
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A client is admitted with community-acquired pneumonia. For each finding, indicate whether it is a cue that the client may be developing sepsis or is not a sepsis cue.
Sepsis cue Not a sepsis cue Temperature 35.7°C (96.3°F) Heart rate 108/min Respiratory rate 16/min WBC 3,600/mm³ (4,500–11,000/mm³) Urine output 55 mL/hour New disorientation to place and date Select one option in each row.
Correct answer: Temperature 35.7°C (96.3°F): Sepsis cue; Heart rate 108/min: Sepsis cue; Respiratory rate 16/min: Not a sepsis cue; WBC 3,600/mm³ (4,500–11,000/mm³): Sepsis cue; Urine output 55 mL/hour: Not a sepsis cue; New disorientation to place and date: Sepsis cue
Sepsis is an infection-triggered, body-wide inflammatory response, so the nurse looks for a cluster of inflammatory cues in a client with an infection. Temperature over 38°C or under 36°C, heart rate over 90/min, respiratory rate over 20/min, and WBC over 12,000 or under 4,000/mm³ are the classic cues. New confusion and urine output under 30 mL/hour point to poor perfusion. Remember that a low temperature and a low WBC count are sepsis cues too.
- Temperature 35.7°C (96.3°F) A temperature under 36°C (96.8°F) is a sepsis cue; sepsis can lower body temperature as well as raise it.
- Heart rate 108/min A heart rate over 90/min is one of the inflammatory-response cues.
- Respiratory rate 16/min A respiratory rate of 16/min is within normal limits; the cue is a rate over 20/min.
- WBC 3,600/mm³ (4,500–11,000/mm³) A WBC under 4,000/mm³ is a sepsis cue, just like a WBC over 12,000/mm³.
- Urine output 55 mL/hour Urine output of 55 mL/hour is above the 30 mL/hour threshold, so kidney perfusion is adequate.
- New disorientation to place and date A new change in mental status can be an early sign of sepsis from poor brain perfusion.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) · OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · MedlinePlus Medical Encyclopedia: WBC count ·
A client with a urinary tract infection has a temperature of 38.9°C (102°F), a heart rate of 116/min, and a blood pressure of 98/60 mm Hg. The provider prescribes blood cultures, a broad-spectrum IV antibiotic, a lactate level, and an IV crystalloid bolus. The bolus is already infusing. Which action should the nurse take next?
Correct answer: B
In suspected sepsis, blood cultures are obtained before broad-spectrum antibiotics so the organism can be identified and the antibiotic adjusted to it later, and the first antibiotic dose is then given immediately because each hour of delay raises mortality. Culture results take 1 to 3 days, so waiting for them is unsafe. Fluids come before vasopressors.
- A Cultures are drawn before the first dose so the organism can still be identified; giving the antibiotic first reverses the required order.
- B Correct: cultures before the antibiotic, then the antibiotic right away, follows the time-sensitive sepsis bundle.
- C Blood cultures take 1 to 3 days; delaying the antibiotic that long increases the risk of death.
- D IV fluids are given first for hypotension in sepsis; a vasopressor such as norepinephrine is added if pressure stays low after fluids.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · CDC: Caring for Patients with Sepsis ·
A client with sepsis has received the full prescribed IV crystalloid bolus. Blood pressure is now 82/44 mm Hg (MAP 57 mm Hg), and lactate is 4.6 mmol/L (less than 2 mmol/L). The client is most likely experiencing . The nurse should anticipate a prescription for , titrated to keep the mean arterial pressure at or above .
Choose the best option from each list to complete the sentence.
Correct answer: septic shock; norepinephrine; 65 mm Hg
Septic shock is sepsis with low blood pressure that persists despite adequate IV fluids; a lactate above 4 mmol/L signals severe hypoperfusion. Once fluids have been given, norepinephrine is the first-line vasopressor. The usual goal is a mean arterial pressure of 65 mm Hg, the level that indicates adequate perfusion pressure.
- Hypotension that persists after adequate fluid resuscitation in a client with sepsis defines septic shock; nothing suggests bleeding or pump failure, and a falling MAP with rising lactate is not a response to treatment.
- Norepinephrine is the first-line vasopressor after fluids; furosemide would remove volume, insulin does not raise pressure, and bicarbonate does not treat the cause of hypotension.
- The treatment target is a MAP of 65 mm Hg or higher; 55 mm Hg is too low to perfuse organs, and 90 or 110 mm Hg are not the standard goal.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) ·
A client with chronic kidney disease has a serum potassium of 6.6 mEq/L (3.5–5.1 mEq/L). The cardiac monitor shows tall, peaked T waves and a widened QRS complex. All of the following are prescribed. Which should the nurse give first?
Correct answer: C
Hyperkalemia with ECG changes can progress to dysrhythmias and cardiac arrest, so the immediate threat to circulation comes first. IV calcium gluconate protects the heart muscle from the effects of potassium within minutes; it is temporary and does not lower the level, which buys time for treatments that remove or shift potassium. Diet changes and binders work too slowly for an emergency.
- A The binder removes potassium through the GI tract, but it acts slowly and does not protect the heart right now.
- B A loop diuretic helps the kidneys excrete potassium, but it does not protect the heart right now, so it is not the first step when the ECG is changing.
- C Correct: calcium gluconate stabilizes cardiac muscle immediately, addressing the most life-threatening problem first.
- D Dietary restriction helps prevent future hyperkalemia but does nothing for a dangerous level that is affecting the heart now.
Learn this topic: How sodium and potassium imbalances show up and what the nurse does 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · OpenStax Medical-Surgical Nursing, 10.3 Electrolyte Imbalance · MedlinePlus Medical Encyclopedia: High potassium level ·
A client taking furosemide has a serum potassium of 2.9 mEq/L (3.5–5.1 mEq/L). Which findings should the nurse expect? Select all that apply.
Select all that apply.
Correct answer: A, C, D, F
Loop diuretics such as furosemide cause potassium loss in the urine. Low potassium weakens muscle contraction and changes cardiac repolarization, giving weakness, lethargy, a thready pulse, dysrhythmias and prominent U waves. Peaked T waves belong to high potassium, and intense thirst with sticky mucous membranes points to high sodium.
- A Muscle weakness is a classic sign of hypokalemia because potassium is needed for muscle contraction.
- B Tall, peaked T waves are the ECG sign of hyperkalemia, the opposite imbalance.
- C A prominent U wave after the T wave is commonly associated with hypokalemia.
- D A weak, thready pulse is listed among hypokalemia signs.
- E Severe thirst and sticky mucous membranes describe hypernatremia, not low potassium.
- F Lethargy is one of the expected signs of hypokalemia.
Learn this topic: How sodium and potassium imbalances show up and what the nurse does 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · OpenStax Pharmacology for Nurses, 5.2 Electrolytes · Open RN Nursing Advanced Skills, 7.3 A Systematic Approach to Interpreting an ECG ·
A client with the syndrome of inappropriate antidiuretic hormone (SIADH) has a serum sodium of 121 mEq/L (136–145 mEq/L) and reports a headache. For each nursing action, indicate whether it is indicated or contraindicated.
Indicated Contraindicated Limit free-water intake as prescribed Encourage the client to drink extra water Infuse 0.45% sodium chloride (a hypotonic fluid) Assess orientation and monitor for seizure activity Raise the sodium to 136 mEq/L within 2 hours Measure intake and output Select one option in each row.
Correct answer: Limit free-water intake as prescribed: Indicated; Encourage the client to drink extra water: Contraindicated; Infuse 0.45% sodium chloride (a hypotonic fluid): Contraindicated; Assess orientation and monitor for seizure activity: Indicated; Raise the sodium to 136 mEq/L within 2 hours: Contraindicated; Measure intake and output: Indicated
SIADH makes the body hold too much water, which dilutes sodium and swells brain cells, causing headache, confusion and seizures. Care limits water, avoids hypotonic fluids, and watches neurologic status and fluid balance. Sodium must be raised slowly: an increase faster than about 0.5 mEq/L per hour risks osmotic demyelination syndrome.
- Limit free-water intake as prescribed Limiting water intake treats dilutional hyponatremia by letting the sodium concentration rise.
- Encourage the client to drink extra water Extra water would dilute the sodium further and worsen brain swelling.
- Infuse 0.45% sodium chloride (a hypotonic fluid) Hypotonic IV fluid adds free water and can cause or worsen hyponatremia.
- Assess orientation and monitor for seizure activity Water moving into brain cells causes confusion and seizures, so neurologic checks are essential.
- Raise the sodium to 136 mEq/L within 2 hours A 15 mEq/L rise in 2 hours is far faster than about 0.5 mEq/L per hour and risks osmotic demyelination syndrome.
- Measure intake and output Accurate intake and output shows whether the water restriction is working.
Learn this topic: How sodium and potassium imbalances show up and what the nurse does 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · OpenStax Medical-Surgical Nursing, 10.3 Electrolyte Imbalance · MedlinePlus Medical Encyclopedia: Low blood sodium ·
The nurse is caring for clients admitted with hyperglycemic crises. For each finding, indicate whether it is consistent with diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), or both.
DKA HHS Both Deep, rapid, labored breathing Glucose 920 mg/dL (fasting 70–99 mg/dL) with arterial pH 7.38 (7.35–7.45) Fruity odor on the breath Excessive thirst and frequent urination Large amount of ketones in the blood and urine Symptoms building over 10 days in an older adult with type 2 diabetes Select one option in each row.
Correct answer: Deep, rapid, labored breathing: DKA; Glucose 920 mg/dL (fasting 70–99 mg/dL) with arterial pH 7.38 (7.35–7.45): HHS; Fruity odor on the breath: DKA; Excessive thirst and frequent urination: Both; Large amount of ketones in the blood and urine: DKA; Symptoms building over 10 days in an older adult with type 2 diabetes: HHS
DKA comes from a near-total lack of insulin, so fat breakdown produces ketones and metabolic acidosis, with Kussmaul breathing and fruity breath. HHS occurs when some insulin remains, so ketones stay low and pH stays normal, but glucose climbs very high (often above 600 mg/dL) over days to weeks. Both cause thirst and frequent urination from high glucose.
- Deep, rapid, labored breathing Kussmaul respirations are the lungs blowing off CO2 to offset ketoacidosis, a DKA finding.
- Glucose 920 mg/dL (fasting 70–99 mg/dL) with arterial pH 7.38 (7.35–7.45) Extreme glucose with a normal pH fits HHS, where there is little or no ketoacidosis.
- Fruity odor on the breath Fruity breath comes from ketones, so it points to DKA.
- Excessive thirst and frequent urination High glucose causes thirst and urination in both crises.
- Large amount of ketones in the blood and urine Large amounts of ketones in blood and urine define DKA; in HHS ketones are absent or only mild.
- Symptoms building over 10 days in an older adult with type 2 diabetes HHS develops slowly over days to weeks and is typical of type 2 diabetes, often in older adults.
Learn this topic: Diabetic ketoacidosis vs hyperosmolar hyperglycemic state 5-minute lesson
Source: Open RN Health Alterations, 7.5 Diabetes Mellitus · OpenStax Medical-Surgical Nursing, 21.2 Diabetes Mellitus · MedlinePlus Medical Encyclopedia: Blood sugar test · Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance ·
A client with diabetic ketoacidosis has received 1 L of 0.9% sodium chloride. Current results: glucose 486 mg/dL (fasting 70–99 mg/dL), arterial pH 7.18 (7.35–7.45), potassium 3.1 mEq/L (3.5–5.1 mEq/L). A continuous IV insulin infusion is prescribed. Which action should the nurse take first?
Correct answer: B
Insulin and correction of acidosis drive potassium into the cells, so serum potassium falls during DKA treatment. When potassium is already below 3.5 mEq/L, insulin is delayed and potassium is replaced first (per protocol or after notifying the provider) to prevent dangerous dysrhythmias and muscle weakness. Safety of the heart comes before lowering glucose.
- A Starting insulin now would push the already low potassium even lower and risk life-threatening dysrhythmias.
- B Correct: current guidance delays insulin and replaces potassium first when potassium is below 3.5 mEq/L.
- C Bicarbonate is not routine in DKA and is considered only when pH is below 7.0; it would also lower potassium.
- D Dextrose is added only after glucose falls below about 250 mg/dL; at 486 mg/dL it is not indicated.
Learn this topic: Diabetic ketoacidosis vs hyperosmolar hyperglycemic state 5-minute lesson
Source: Umpierrez GE et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care 2024 (PMC) · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · Open RN Health Alterations, 7.5 Diabetes Mellitus ·
A client is receiving an IV insulin infusion for diabetic ketoacidosis. Four hours later, the glucose is 236 mg/dL (fasting 70–99 mg/dL), arterial pH is 7.26 (7.35–7.45), and bicarbonate is 13 mEq/L (22–26 mEq/L). The nurse anticipates because .
Choose the best option from each list to complete the sentence.
Correct answer: adding 5–10% dextrose to the IV fluid; the ketoacidosis has not yet resolved
Glucose usually falls faster than ketoacidosis clears. Once glucose drops below 250 mg/dL, 5–10% dextrose is added to the IV fluid and the insulin rate is lowered, so insulin can keep clearing ketones without causing hypoglycemia. A pH of 7.26 and bicarbonate of 13 mEq/L show the acidosis is still present.
- Adding dextrose lets the insulin infusion continue safely; stopping insulin would let ketoacidosis persist, a 50% dextrose bolus treats hypoglycemia that is not present, and doubling insulin would drive glucose too low.
- The pH and bicarbonate are still low, so the ketoacidosis has not resolved; glucose is above normal, the client is not hypoglycemic, and ketone clearance is incomplete.
Learn this topic: Diabetic ketoacidosis vs hyperosmolar hyperglycemic state 5-minute lesson
Source: Umpierrez GE et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care 2024 (PMC) · Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · MedlinePlus Medical Encyclopedia: Blood sugar test ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L The nurse reviews the 0700 note. Click to highlight the findings that require follow-up.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the . Reports . Skin warm and flushed. Lung sounds . Skin over the sacrum . Urine in the drainage bag is cloudy, dark amber and ; in the past 4 hours. Capillary refill . Provider notified.
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: place or date; chills; foul-smelling; 90 mL
The client was oriented last evening, so new disorientation is an acute change and, in an older adult, can be one of the first signs of sepsis. Chills and foul-smelling cloudy urine in a client with a long-term catheter point to a spreading urinary infection. Ninety mL in 4 hours is about 22 mL/hour, below the 30 mL/hour that signals adequate kidney perfusion.
- place or date New disorientation compared with last evening is an acute mental status change that needs immediate follow-up.
- chills Chills with a rising temperature are a sign of sepsis.
- clear bilaterally Clear lung sounds are a normal finding and make the lungs an unlikely source.
- intact Intact sacral skin is a normal finding.
- foul-smelling Foul-smelling, cloudy urine in a client with an indwelling catheter suggests the urinary tract is the infection source.
- 90 mL About 22 mL/hour is below 30 mL/hour and signals poor kidney perfusion.
- 2 seconds A capillary refill of 2 seconds is within normal limits.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) · OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · OpenStax Medical-Surgical Nursing, 23.1 Shock Overview · CDC: About Sepsis · MedlinePlus Medical Encyclopedia: Septic shock · MedlinePlus Medical Encyclopedia: WBC count ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L For each finding, indicate whether it mainly reflects the infection and inflammatory response or decreased tissue perfusion.
Infection or inflammatory response Decreased tissue perfusion Temperature 39.1°C (102.4°F) WBC 16,800/mm³ (4,500–11,000/mm³) Cloudy, foul-smelling urine Lactate 3.4 mmol/L (less than 2 mmol/L) 90 mL of urine in 4 hours New disorientation to place and date Select one option in each row.
Correct answer: Temperature 39.1°C (102.4°F): Infection or inflammatory response; WBC 16,800/mm³ (4,500–11,000/mm³): Infection or inflammatory response; Cloudy, foul-smelling urine: Infection or inflammatory response; Lactate 3.4 mmol/L (less than 2 mmol/L): Decreased tissue perfusion; 90 mL of urine in 4 hours: Decreased tissue perfusion; New disorientation to place and date: Decreased tissue perfusion
Fever, a high WBC count and infected urine show the infection and the body-wide inflammatory response. When perfusion falls, cells switch to anaerobic metabolism and lactate rises, the kidneys make less urine, and the brain becomes confused or agitated. Perfusion cues tell the nurse that sepsis is affecting organs and that shock may follow.
- Temperature 39.1°C (102.4°F) Fever is part of the inflammatory response to infection.
- WBC 16,800/mm³ (4,500–11,000/mm³) A WBC over 12,000/mm³ reflects the immune response to infection.
- Cloudy, foul-smelling urine Cloudy, foul-smelling urine is a local sign of the urinary infection.
- Lactate 3.4 mmol/L (less than 2 mmol/L) Lactate rises when poorly perfused cells switch to anaerobic metabolism.
- 90 mL of urine in 4 hours Output of about 22 mL/hour, under 30 mL/hour, reflects poor kidney perfusion.
- New disorientation to place and date Agitation and confusion appear as brain perfusion drops.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · OpenStax Medical-Surgical Nursing, 23.1 Shock Overview · Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L Complete the following sentences. The client's findings are most consistent with that most likely began in the . Without prompt treatment, the client is at highest risk for progressing to .
Choose the best option from each list to complete the sentence.
Correct answer: sepsis; urinary tract; septic shock
A client with an infection who develops fever, tachycardia, tachypnea, a high WBC count, new confusion, low urine output and a rising lactate has sepsis. The catheter, cloudy foul-smelling urine and clear lungs point to a urinary source. With a borderline blood pressure and a lactate above 2 mmol/L, the most urgent risk is septic shock, which is why this hypothesis is ranked first.
- The cluster of inflammatory and perfusion cues in an infected client is sepsis; there are no ketone or glucose data to support DKA, and delirium or simple dehydration would not explain the fever and high WBC count.
- The long-term catheter and abnormal urine identify the urinary tract; lungs are clear, and there are no skin or GI findings.
- Falling blood pressure with rising lactate signals progression toward septic shock; potassium is normal, and nothing suggests fluid overload or low glucose.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) · OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · MedlinePlus Medical Encyclopedia: Septic shock · CDC: About Sepsis ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Actions to take (choose 2)
Condition most likely (choose 1)
Parameters to monitor (choose 2)
Correct answer: Sepsis; Draw blood cultures before the antibiotic; Infuse the prescribed crystalloid bolus; Hourly urine output; Serum lactate
The client has sepsis from a urinary source. Early actions are blood cultures before the first antibiotic dose and IV crystalloid to restore perfusion. Lactate and hourly urine output show whether tissue perfusion is improving, with targets of lactate below 2 mmol/L and urine output of at least 30 mL/hour.
- Diabetic ketoacidosis There are no ketone, pH or glucose data supporting DKA.
- Acute pulmonary edema Lung sounds are clear and SpO2 is 95%, so pulmonary edema is unlikely.
- Sepsis Correct: infection plus fever, tachycardia, tachypnea, high WBC, confusion, low urine output and high lactate indicate sepsis.
- Restrict fluids to 1,000 mL per day Fluid restriction would worsen hypoperfusion in sepsis.
- Draw blood cultures before the antibiotic Correct: cultures are drawn before broad-spectrum antibiotics so the organism can be identified.
- Start a continuous IV infusion of regular insulin An insulin infusion treats DKA or HHS, not sepsis.
- Give furosemide by IV push A diuretic would remove volume from a client who needs fluid resuscitation.
- Infuse the prescribed crystalloid bolus Correct: IV crystalloid restores intravascular volume and perfusion in sepsis.
- Serum ketones Ketones monitor DKA, which this client does not have.
- Hourly urine output Correct: hourly urine output reflects kidney perfusion; the goal is at least 30 mL/hour.
- Hemoglobin A1C Hemoglobin A1C reflects glucose control over months and does not track acute sepsis.
- Serum lactate Correct: a falling lactate shows that cells are getting enough oxygen again.
- Peak expiratory flow rate Peak flow monitors airway obstruction such as asthma, not sepsis.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) · CDC: Caring for Patients with Sepsis ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L The provider prescribes 2 sets of blood cultures, a broad-spectrum IV antibiotic, a repeat lactate level in 2 hours, and a 0.9% sodium chloride IV bolus. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, D, F
The sepsis bundle is time-sensitive: obtain cultures before antibiotics, give the first antibiotic dose immediately, restore volume with IV crystalloid, and monitor perfusion closely. Hourly urine output is a simple bedside measure of kidney perfusion. Delaying the antibiotic or relying on oral fluids in a confused, hypotensive client is unsafe.
- A Cultures are drawn before the first antibiotic dose so the organism can be identified and the antibiotic adjusted to it later.
- B Culture results take 1 to 3 days; delaying antibiotics that long increases mortality.
- C The first antibiotic dose should be given immediately once cultures are obtained.
- D IV crystalloid is the first treatment for sepsis-related hypotension and hypoperfusion.
- E A confused client with low blood pressure needs IV volume; oral fluids are too slow and unsafe for a client who is not fully alert.
- F Hourly output tracks kidney perfusion; less than 30 mL/hour must be reported.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · CDC: Caring for Patients with Sepsis ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L Three hours after treatment began, the nurse reassesses the client. For each finding, indicate whether it shows that treatment has been effective or ineffective.
Effective Ineffective Blood pressure 104/58 mm Hg (MAP 73 mm Hg) Urine output 45 mL in the past hour Repeat lactate 3.9 mmol/L (less than 2 mmol/L) Oriented to person, place and date New mottling of the skin over both knees Select one option in each row.
Correct answer: Blood pressure 104/58 mm Hg (MAP 73 mm Hg): Effective; Urine output 45 mL in the past hour: Effective; Repeat lactate 3.9 mmol/L (less than 2 mmol/L): Ineffective; Oriented to person, place and date: Effective; New mottling of the skin over both knees: Ineffective
Treatment goals in sepsis are a MAP of at least 65 mm Hg, urine output of at least 30 mL/hour, a falling lactate and a return to baseline mental status. A lactate that rises from 3.4 to 3.9 mmol/L and new skin mottling are signs of worsening perfusion even when blood pressure improves, so the nurse reports them right away.
- Blood pressure 104/58 mm Hg (MAP 73 mm Hg) A MAP of 73 mm Hg meets the goal of 65 mm Hg or higher.
- Urine output 45 mL in the past hour Output of 45 mL/hour exceeds the 30 mL/hour goal, showing better kidney perfusion.
- Repeat lactate 3.9 mmol/L (less than 2 mmol/L) Lactate has risen from 3.4 mmol/L instead of falling, so tissue hypoperfusion is not resolving.
- Oriented to person, place and date Return to the client's baseline orientation shows improved brain perfusion.
- New mottling of the skin over both knees Mottled skin is a sign of worsening (cold) shock and poor peripheral perfusion.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · OpenStax Medical-Surgical Nursing, 23.1 Shock Overview ·
A client lying in bed begins a generalized tonic-clonic seizure. The nurse removes the extra pillows, raises the side rails and should . If the seizure continues for more than , the nurse calls for emergency assistance because the client is in status epilepticus. When the jerking stops, the nurse places the client .
Choose the best option from each list to complete the sentence.
Correct answer: note the time the seizure started; 5 minutes; on one side
During a seizure the nurse protects the client from injury and observes: nothing goes in the mouth, the client is not restrained, and the start and end times are recorded. A seizure lasting more than 5 minutes is status epilepticus, an emergency that needs immediate help. Afterward, the client is kept on one side to prevent aspiration.
- Recording the start time is a key nursing action; objects in the mouth can break teeth or injure the tongue, restraining the client causes injury, and moving a convulsing client into a chair is unsafe.
- Status epilepticus is a seizure lasting more than 5 minutes (or repeated seizures without recovery between them); waiting 15 or 30 minutes delays emergency care, and 1 minute is shorter than a typical tonic-clonic seizure, which lasts about 2 to 5 minutes.
- Keeping the client on one side is the recommended position to prevent aspiration; lying on the back, sitting upright and lying face down are not the recommended position after a seizure.
Source: Open RN Health Alterations, 9.7 Seizures and Epilepsy ·
A client on a medical unit was seen by the assistive personnel at 0545 talking normally and asking for water. At 0720 the nurse finds the client with a drooping mouth on the left side and slurred speech. The client cannot say when the symptoms started. Which time should the nurse report to the stroke team as the onset of symptoms?
Correct answer: B
Stroke onset is counted from the time the client was last known well, meaning last seen without symptoms. Here that is 0545, when the client was talking normally. The time symptoms were discovered (0720) is later than the true onset, and using it could make the client look eligible for time-sensitive treatment when they are not.
- A 0720 is when the symptoms were found, not the last time the client was known to be well.
- B Correct: 0545 is the last time the client was seen acting normally, so it is the time last known well.
- C The time of the stroke response call does not tell the team when the brain lost its blood flow.
- D The time of the previous evening's assessment is not the most recent time the client was known to be well.
Learn this topic: How do you recognize an acute stroke and what does the nurse do first? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 15.2 Ischemic Stroke · CDC, Signs and Symptoms of Stroke ·
A stroke alert is called for a client with sudden right arm weakness and trouble speaking that began 50 minutes ago. While the stroke team is on the way, which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, D, F
In a suspected stroke, the nurse gathers time-critical data and keeps the client safe. A fingerstick glucose rules out hypoglycemia, which can mimic stroke. The client stays NPO, including oral medications such as scheduled aspirin, until a swallow screen is done. Two large-bore IV lines and an accurate weight are needed before a thrombolytic, because its dose is weight-based.
- A Correct: hypoglycemia can mimic a stroke, so glucose is checked early.
- B Nothing is given by mouth, including medications, until a swallow screen shows it is safe.
- C Correct: an accurate weight is needed because thrombolytic doses are weight-based.
- D Correct: the client is kept NPO to prevent aspiration until a trained nurse or speech-language pathologist completes a swallow screen.
- E Giving water to test swallowing before a formal swallow screen risks aspiration.
- F Correct: two large-bore IV lines are part of preparing for imaging and possible thrombolytic therapy.
Learn this topic: How do you recognize an acute stroke and what does the nurse do first? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 15.2 Ischemic Stroke · Open RN Health Alterations, 9.9 Cerebrovascular Accident ·
A client with an ischemic stroke is 1 hour into an IV alteplase infusion. Before treatment the client had right arm weakness. For each finding, indicate whether it requires the nurse's immediate action or can be addressed with continued routine monitoring.
Immediate action Routine monitoring New severe headache and vomiting Blood pressure 168/94 mm Hg Swelling of the tongue and lips Right arm weakness unchanged from before the infusion Client, alert before the infusion, now opens eyes only to a loud voice Select one option in each row.
Correct answer: New severe headache and vomiting: Immediate action; Blood pressure 168/94 mm Hg: Routine monitoring; Swelling of the tongue and lips: Immediate action; Right arm weakness unchanged from before the infusion: Routine monitoring; Client, alert before the infusion, now opens eyes only to a loud voice: Immediate action
The major risk of a thrombolytic is bleeding, especially into the brain. A new severe headache with vomiting or a falling level of consciousness can mean hemorrhagic transformation, and lip or tongue swelling is angioedema; the label says to stop the infusion for serious bleeding or angioedema, so these need immediate action. A blood pressure within the 180/105 mm Hg limit and weakness unchanged from before treatment are monitored routinely.
- New severe headache and vomiting Immediate action: a sudden severe headache with vomiting may be bleeding in the brain.
- Blood pressure 168/94 mm Hg Routine monitoring: 168/94 mm Hg is within the limit of 180/105 mm Hg or lower used for clients receiving a thrombolytic.
- Swelling of the tongue and lips Immediate action: swelling of the tongue and lips during alteplase is angioedema, a reason to stop the infusion.
- Right arm weakness unchanged from before the infusion Routine monitoring: weakness that is unchanged from before treatment is not a new deficit.
- Client, alert before the infusion, now opens eyes only to a loud voice Immediate action: a falling level of consciousness is a new neurologic decline that may signal bleeding.
Learn this topic: How do you recognize an acute stroke and what does the nurse do first? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 15.2 Ischemic Stroke · DailyMed, Alteplase for injection prescribing information · Open RN Health Alterations, 9.9 Cerebrovascular Accident ·
A client who has had severe diarrhea for 3 days has these arterial blood gas results: pH 7.29 (7.35–7.45), PaCO2 30 mm Hg (35–45 mm Hg), HCO3 16 mEq/L (22–26 mEq/L). How should the nurse interpret these results?
Correct answer: C
Start with the pH: 7.29 is acidosis. HCO3 is low and moves in the same direction as the pH, so the cause is metabolic (Metabolic Equal); severe diarrhea removes bicarbonate. PaCO2 is also low because the lungs are blowing off CO2 to compensate, but the pH is still abnormal, so the compensation is partial.
- A Respiratory acidosis would need a PaCO2 above 45 mm Hg; here PaCO2 is low.
- B Uncompensated would mean PaCO2 is still normal; here it is already below 35 mm Hg.
- C Correct: pH and HCO3 are both low (metabolic acidosis), and the low PaCO2 shows the lungs are compensating while the pH is still abnormal.
- D Full compensation would bring the pH back into the 7.35–7.45 range.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance ·
A client with a fractured femur is in severe pain, breathing 30 times per minute and reports numb, tingling fingers. ABG results: pH 7.50 (7.35–7.45), PaCO2 29 mm Hg (35–45 mm Hg), HCO3 24 mEq/L (22–26 mEq/L). The nurse interprets the results as that is . In addition to giving the prescribed analgesic, the nurse should .
Choose the best option from each list to complete the sentence.
Correct answer: respiratory alkalosis; uncompensated; coach slow abdominal breathing with a longer exhale
A high pH with a low PaCO2 (moving opposite to the pH) is respiratory alkalosis, caused here by pain-driven hyperventilation. HCO3 is still normal, so the kidneys have not begun to compensate. Treatment targets the cause: relieve the pain, reassure the client and coach slow abdominal breathing; rebreathing into a paper bag is no longer recommended because it can cause hypoxemia.
- PaCO2 is low and moves opposite to the high pH, so the cause is respiratory alkalosis; metabolic alkalosis would need a high HCO3, and acidosis would need a low pH.
- HCO3 is still in the normal range, so the imbalance is uncompensated; partial compensation would show a low HCO3, and full compensation would bring the pH back to normal.
- Slow abdominal breathing with a longer exhale reduces CO2 loss; a paper bag can cause hypoxemia, deep breathing to blow off CO2 worsens alkalosis, and bicarbonate would add base.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance · MedlinePlus, Respiratory alkalosis ·
For each client, indicate the acid–base imbalance the nurse should anticipate.
Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis A client who received several doses of an opioid has a respiratory rate of 7/min A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L) A sedated client on a mechanical ventilator has a set rate that is too high for the client A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L) Select one option in each row.
Correct answer: A client who received several doses of an opioid has a respiratory rate of 7/min: Respiratory acidosis; A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L): Metabolic acidosis; A sedated client on a mechanical ventilator has a set rate that is too high for the client: Respiratory alkalosis; A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L): Metabolic alkalosis
Match the imbalance to the cause. Too little breathing retains CO2 (respiratory acidosis); too much breathing removes CO2 (respiratory alkalosis). Acid build-up such as lactic acid from poor perfusion causes metabolic acidosis, while loss of hydrogen ions through the urine with diuretics or a shift of hydrogen into cells in hypokalemia causes metabolic alkalosis.
- A client who received several doses of an opioid has a respiratory rate of 7/min Respiratory acidosis: opioid oversedation slows breathing, so CO2 builds up.
- A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L) Metabolic acidosis: poor tissue oxygenation in shock produces lactic acid.
- A sedated client on a mechanical ventilator has a set rate that is too high for the client Respiratory alkalosis: a ventilator rate that is too high removes too much CO2.
- A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L) Metabolic alkalosis: diuretics cause loss of hydrogen ions in the urine, and hypokalemia shifts hydrogen ions into cells.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance · OpenStax Medical-Surgical Nursing, 23.2 Hypovolemic Shock · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes ·
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NCLEX-RN format
| Client needs category | Share of the exam |
|---|---|
| Management of Care | 15–21% |
| Safety and Infection Prevention and Control | 10–16% |
| Health Promotion and Maintenance | 6–12% |
| Psychosocial Integrity | 6–12% |
| Basic Care and Comfort | 6–12% |
| Pharmacological and Parenteral Therapies | 13–19% |
| Reduction of Risk Potential | 9–15% |
| Physiological Adaptation | 11–17% |
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