Nclexrn Quiz: Sepsis And Shock Recognition And Priorities
20 questions · exam conditions
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Sepsis And Shock Recognition And PrioritiesQuestion 1 of 20

A 71-year-old client is 2 days post hip replacement and reports feeling "cold and shaky." Assessment: temperature 39.0°C, heart rate 118/min, blood pressure 92/52 mm Hg, respiratory rate 22/min, oxygen saturation 95% on 2 L nasal cannula; incision is clean but the urinary catheter drainage is cloudy; white blood cell count 16,400/mm³ (4,500–11,000). Which intervention should be implemented IMMEDIATELY?

Obtain a urine culture from the catheter sampling port using sterile technique
Increase intravenous fluids per sepsis protocol and reassess blood pressure frequently
Apply warm blankets to treat chills and promote comfort
Delegate incentive spirometry coaching to unlicensed assistive personnel
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Nclexrn Quiz

Nclexrn Quiz: Sepsis And Shock Recognition And Priorities

Practice Sepsis And Shock Recognition And Priorities in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Sepsis And Shock Recognition And Priorities, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

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Question 1

A 71-year-old client is 2 days post hip replacement and reports feeling "cold and shaky." Assessment: temperature 39.0°C, heart rate 118/min, blood pressure 92/52 mm Hg, respiratory rate 22/min, oxygen saturation 95% on 2 L nasal cannula; incision is clean but the urinary catheter drainage is cloudy; white blood cell count 16,400/mm³ (4,500–11,000). Which intervention should be implemented IMMEDIATELY?

  1. Obtain a urine culture from the catheter sampling port using sterile technique
  2. Increase intravenous fluids per sepsis protocol and reassess blood pressure frequently (correct answer)
  3. Apply warm blankets to treat chills and promote comfort
  4. Delegate incentive spirometry coaching to unlicensed assistive personnel
Explanation: This question tests recognition and prioritization in postoperative sepsis from possible UTI. The priority framework is the ABCs, focusing on circulation due to hypotension. Increasing intravenous fluids per sepsis protocol and reassessing blood pressure frequently is the highest priority to address hypoperfusion. Obtaining a urine culture, applying warm blankets, and delegating incentive spirometry are lower priority as diagnostics, comfort, and prevention follow hemodynamic stabilization. In postoperative sepsis, fluid resuscitation is key to maintaining organ perfusion. The decision-making principle prioritizes circulatory support over source identification. A generalizable prioritization strategy is to bolster circulation immediately in hypotensive sepsis using ABCs.

Question 2

A 6-year-old child is brought to the emergency department with vomiting and high fever for 1 day. Assessment: temperature 39.6°C, heart rate 156/min, respiratory rate 40/min with nasal flaring, blood pressure 78/42 mm Hg, capillary refill 5 seconds, oxygen saturation 90% on room air; parent reports fewer wet diapers; lactate 4.1 mmol/L (0.5–2.0). What is the PRIORITY nursing action?

  1. Start a peripheral intravenous line and administer a rapid isotonic fluid bolus per protocol (correct answer)
  2. Collect a urine specimen for urinalysis and culture after the child's perfusion has improved
  3. Administer an oral antipyretic and reassess the child's temperature in 30 minutes
  4. Delegate weight measurement to unlicensed assistive personnel while the child is being evaluated
Explanation: Starting a peripheral intravenous line and administering a rapid isotonic fluid bolus per protocol is the priority. This child has hypotension, tachycardia, tachypnea with nasal flaring, delayed capillary refill, decreased urine output, and elevated lactate—findings of septic shock. The immediate need is to restore circulation with volume expansion. Collecting a urine specimen for urinalysis and culture after perfusion improves is a diagnostic step; it does not treat shock and should not come before resuscitation. Administering an oral antipyretic and reassessing in 30 minutes treats fever, not poor perfusion; oral absorption is unreliable in hypoperfusion, and the delay is unsafe. Delegating weight measurement to unlicensed assistive personnel is not the priority; although weight may be useful for dosing, obtaining vascular access and giving fluid is the life-saving action. Use ABCs and emphasize circulation when shock is suspected: a rapid isotonic fluid bolus is the first response.

Question 3

A 7-year-old child is admitted with suspected sepsis from cellulitis. Findings: temperature 39.3°C, heart rate 150/min, respiratory rate 36/min, blood pressure 82/46 mm Hg, oxygen saturation 95% on room air; the child is sleepy but arousable. Which intervention should be implemented IMMEDIATELY?

  1. Apply a warm compress to the affected area to improve circulation
  2. Start supplemental oxygen and establish intravenous access for rapid isotonic fluid bolus (correct answer)
  3. Obtain a detailed pain assessment and administer oral analgesics
  4. Collect a wound swab for culture after cleansing the site
Explanation: This question tests recognition and prioritization in pediatric sepsis from cellulitis. The priority framework is the ABCs, addressing breathing and circulation due to tachycardia and hypotension. Starting supplemental oxygen and establishing intravenous access for rapid isotonic fluid bolus is the highest priority to support oxygenation and perfusion. Applying a warm compress, assessing pain with oral analgesics, and collecting a wound swab are lower priority as local care, pain management, and diagnostics follow stabilization. In pediatric sepsis, immediate resuscitation is vital. The decision-making principle prioritizes ABCs in unstable children. A generalizable prioritization strategy is to initiate oxygen and fluids first in septic shock using ABCs.

Question 4

A 58-year-old client presents to the emergency department with cough and fever for 3 days; the client is lethargic and difficult to arouse. Current findings: temperature 38.86C (101.86F), heart rate 118/min, respiratory rate 30/min, blood pressure 86/50 mm Hg, oxygen saturation 88% on room air, lactate 5.2 mmol/L (reference 0.52.2). The nurse should QUESTION which order in this situation?

  1. Administer broad-spectrum intravenous antibiotics after obtaining ordered cultures
  2. Infuse 30 mL/kg isotonic crystalloid bolus
  3. Give furosemide 40 mg intravenous push now for suspected fluid overload (correct answer)
  4. Apply oxygen and titrate to maintain oxygen saturation at or above 94%
Explanation: This question tests recognition and prioritization by identifying an inappropriate order in septic shock management. The priority framework is recognizing contraindications in shock states. The correct answer C (furosemide for fluid overload) should be questioned because the patient is in septic shock with hypotension and needs fluid resuscitation, not diuresis. Options A (antibiotics after cultures), B (fluid bolus), and D (oxygen therapy) are all appropriate interventions for septic shock; giving furosemide would worsen hypotension and tissue perfusion in a patient who needs volume expansion, not depletion. The critical principle in septic shock is that hypotension with elevated lactate indicates inadequate tissue perfusion requiring fluid resuscitation - diuretics are contraindicated as they would further reduce intravascular volume. The generalizable strategy is: always question orders that could worsen the primary problem - in septic shock with hypotension, any intervention that reduces intravascular volume (like diuretics) is potentially harmful and should be clarified before implementation.

Question 5

An 88-year-old client in long-term care has a history of heart failure and is being treated for pneumonia. The nurse notes the client is newly lethargic and has decreased urine output. Current findings: temperature 38.16C (100.66F), heart rate 116/min, respiratory rate 24/min, blood pressure 88/48 mm Hg, oxygen saturation 91% on room air; white blood cell count 19,000/mm (reference 4,50011,000). Which intervention should be implemented IMMEDIATELY?

  1. Administer the scheduled oral antibiotic with food to reduce gastrointestinal upset
  2. Place the client supine, apply oxygen, and notify the provider/rapid response team of suspected sepsis with hypotension (correct answer)
  3. Delegate to unlicensed assistive personnel to obtain a urine specimen for urinalysis
  4. Reassess lung sounds and document the presence of crackles or wheezes
Explanation: This question tests recognition and prioritization in sepsis with underlying heart failure. The priority framework combines ABCs with consideration of comorbidities. The correct answer B (position supine, apply oxygen, notify provider/rapid response) is the highest priority because the patient has severe hypotension (88/48 mm Hg) with signs of sepsis requiring immediate intervention while considering the heart failure history. Option A (oral antibiotic) is too slow for this acute situation; option C (urine specimen) delays critical treatment; option D (lung assessment) is important but secondary to addressing shock. In patients with heart failure developing septic shock, careful fluid resuscitation with close monitoring is crucial, requiring immediate provider involvement. The generalizable principle is: when sepsis occurs in patients with cardiac comorbidities, immediately stabilize hemodynamics while rapidly involving providers who can balance fluid resuscitation needs against heart failure risks, as these patients require expert management to prevent both shock progression and pulmonary edema.

Question 6

A 70-year-old client is in the emergency department with suspected septic shock from a skin infection on the lower leg; the client is restless and states, "I feel like I can't think straight." Current findings: temperature 39.06C (102.26F), heart rate 132/min, respiratory rate 26/min, blood pressure 78/40 mm Hg, oxygen saturation 93% on 2 L/min nasal cannula, mottled cool extremities, urine output 10 mL/hr, lactate 6.0 mmol/L (reference 0.52.2). What is the PRIORITY nursing action for this client?

  1. Obtain two sets of blood cultures from separate sites
  2. Initiate rapid infusion of isotonic crystalloid and prepare to start a vasopressor per protocol if hypotension persists (correct answer)
  3. Apply a cooling blanket and administer prescribed antipyretic medication
  4. Complete a full head-to-toe assessment and document all findings
Explanation: This question tests recognition and prioritization in established septic shock with organ dysfunction. The priority framework is circulation and preventing irreversible shock. The correct answer B (rapid crystalloid infusion and prepare vasopressors) is the highest priority because the patient has severe hypotension (78/40 mm Hg) with signs of tissue hypoperfusion (mottled skin, oliguria, elevated lactate, altered mental status) requiring immediate aggressive resuscitation. Option A (blood cultures) is important but secondary to stabilizing hemodynamics; option C (cooling measures) addresses fever but not the life-threatening hypoperfusion; option D (assessment and documentation) delays critical intervention. In septic shock with profound hypotension, fluid resuscitation with preparation for vasopressor support is the immediate priority to prevent irreversible organ damage. The generalizable principle is: when septic shock presents with severe hypotension and multiple organ dysfunction signs, prioritize aggressive hemodynamic support over diagnostic procedures or comfort measures, as every minute of hypoperfusion increases mortality risk.

Question 7

A 54-year-old client arrives to the emergency department with fever, chills, and confusion after 3 days of dysuria; history includes type 2 diabetes. Current findings: temperature 39.2°C, heart rate 128/min, blood pressure 82/46 mm Hg, respiratory rate 28/min, oxygen saturation 93% on room air, lactate 4.6 mmol/L (0.5–2.0), white blood cell count 18,500/mm³ (4,500–11,000), urine cloudy and foul-smelling. What is the PRIORITY nursing action for this client?

  1. Obtain a clean-catch urine specimen for culture and sensitivity
  2. Administer a prescribed acetaminophen dose for fever reduction
  3. Initiate rapid infusion of isotonic crystalloid via two large-bore intravenous lines (correct answer)
  4. Delegate repeat vital signs to unlicensed assistive personnel in 30 minutes
Explanation: This question tests recognition and prioritization in septic shock from urosepsis. The priority framework is the ABCs (airway, breathing, circulation), focusing on circulation due to hypotension and elevated lactate indicating hypoperfusion. Initiating rapid infusion of isotonic crystalloid via two large-bore intravenous lines is the highest priority to restore intravascular volume and improve tissue perfusion. Obtaining a urine specimen, administering acetaminophen, and delegating vital signs are lower priority as they do not immediately address life-threatening hypotension; specimen collection and fever reduction can follow stabilization, while delegation is inappropriate for unstable vital signs. In sepsis and septic shock, early fluid resuscitation is critical to prevent organ failure. The decision-making principle emphasizes addressing circulatory compromise before diagnostic or comfort measures. A generalizable prioritization strategy is to stabilize hemodynamics first in hypotensive shock scenarios using ABCs and sepsis bundles.

Question 8

A 39-year-old client is 24 hours post-op after an open appendectomy and now has new shaking chills and anxiety. Current findings: temperature 39.4∘C39.4^\circ\text{C} (102.9∘F102.9^\circ\text{F}), heart rate 126/min, respiratory rate 28/min, blood pressure 92/56 mm Hg, oxygen saturation 95% on room air; the incision is mildly erythematous with increasing tenderness. Which assessment finding should the nurse address FIRST?

  1. Mild erythema at the incision site
  2. Blood pressure 92/56 mm Hg (correct answer)
  3. Temperature 39.4∘C39.4^\circ\text{C} (102.9∘F102.9^\circ\text{F})
  4. Client reports increasing tenderness at the incision
Explanation: This question tests recognition and prioritization in post-operative sepsis development. The priority framework is ABCs, specifically addressing circulation given the hypotension. The correct answer B (blood pressure 92/56 mm Hg) should be addressed first because hypotension in the setting of post-operative fever and tachycardia indicates potential septic shock requiring immediate intervention. Option A (mild erythema) suggests infection source but isn't immediately life-threatening; option C (high fever) is concerning but secondary to addressing shock; option D (incisional tenderness) indicates local infection but doesn't pose immediate systemic threat. The key principle is that post-operative hypotension with signs of infection represents early septic shock requiring immediate fluid resuscitation to prevent progression. The generalizable strategy is: in post-operative patients with multiple concerning findings, prioritize hemodynamic instability over local signs of infection or fever, as preventing circulatory collapse takes precedence over source control in the immediate phase.

Question 9

A 76-year-old long-term care resident with a chronic indwelling urinary catheter is newly agitated and pulling at lines. Findings: temperature 38.6°C, heart rate 118/min, blood pressure 86/52 mm Hg, respiratory rate 22/min, oxygen saturation 97% on room air; urine is cloudy; white blood cell count 14,800/mm³ (4,500–11,000). What is the PRIORITY nursing action?

  1. Administer a prescribed as-needed anxiolytic medication for the agitation
  2. Initiate intravenous access and begin isotonic fluids per protocol (correct answer)
  3. Obtain a catheter urine specimen for culture and sensitivity testing
  4. Delegate continuous one-to-one observation of the resident to a nursing assistant
Explanation: This resident has fever, cloudy urine, leukocytosis, tachycardia, and hypotension that indicate septic shock. The blood pressure of 86/52 mm Hg is an immediate threat to circulation, so the priority is to support perfusion. Initiating intravenous access and beginning isotonic fluids per protocol expands blood volume while the infection is being investigated. The as-needed anxiolytic treats the agitation as the main problem, but the agitation is a sign of the underlying infection; sedation may also hide worsening neurologic status and does not raise blood pressure. Obtaining a catheter urine specimen for culture and sensitivity is a reasonable diagnostic step, but it should come after the patient is stabilized. Delegating continuous one-to-one observation provides safety monitoring, but a nursing assistant cannot treat the hypotension or deliver the fluids this resident needs. The priority is therefore IV access and fluid resuscitation.

Question 10

A 67-year-old client is 36 hours post hysterectomy and develops shaking chills and increasing incisional pain. Findings: temperature 39.4°C, heart rate 126/min, blood pressure 94/56 mm Hg, respiratory rate 24/min, oxygen saturation 95% on room air; white blood cell count 19,000/mm³ (4,500–11,000), lactate 3.6 mmol/L (0.5–2.0). What is the PRIORITY nursing action?

  1. Encourage use of the incentive spirometer every hour while awake
  2. Administer prescribed as-needed opioid analgesic for incisional pain
  3. Reassess the incision and document drainage characteristics
  4. Notify the provider and activate the facility sepsis protocol (correct answer)
Explanation: This question tests recognition and prioritization in postoperative sepsis. The priority framework is safety, recognizing signs of deterioration. Notifying the provider and activating the facility sepsis protocol is the highest priority to initiate timely interventions for suspected sepsis. Administering an opioid, reassessing the incision, and encouraging incentive spirometry are lower priority as pain management, assessment, and prevention follow alerting for systemic response. In postoperative sepsis, early protocol activation improves outcomes. The decision-making principle involves rapid recognition and escalation. A generalizable prioritization strategy is to activate protocols immediately in suspected sepsis using safety frameworks.

Question 11

A 63-year-old client arrives to the emergency department with suspected urosepsis. Findings: temperature 38.8°C, heart rate 120/min, blood pressure 78/40 mm Hg, respiratory rate 28/min, oxygen saturation 92% on room air, lactate 5.2 mmol/L (0.5–2.0). What is the PRIORITY nursing action?

  1. Insert an indwelling urinary catheter to obtain a sterile urine specimen and monitor urine output.
  2. Initiate continuous cardiac monitoring and obtain a 12-lead electrocardiogram to detect ischemia.
  3. Begin rapid isotonic fluid resuscitation and prepare to administer vasopressors if ordered. (correct answer)
  4. Provide oral fluids in small amounts as tolerated to improve hydration and urine output.
Explanation: In suspected urosepsis with septic shock, the immediate threat is profound hypotension and poor tissue perfusion, shown by the blood pressure of 78/40 mm Hg, tachycardia, tachypnea, and elevated lactate. The priority is to restore circulation: begin rapid isotonic fluid resuscitation and prepare to administer vasopressors if blood pressure does not improve. This action directly treats the shock, whereas the other options are diagnostic, supportive, or not sufficiently aggressive. Inserting an indwelling urinary catheter to obtain a sterile specimen is important for identifying the source, but urine collection does not correct hypotension. Continuous cardiac monitoring and a 12-lead electrocardiogram are useful for surveillance, but they do not treat the failing circulation. Giving oral fluids in small amounts is neither rapid nor safe enough for a client in shock; gastrointestinal perfusion is compromised, and oral intake cannot quickly restore intravascular volume. A systematic approach to this emergency prioritizes interventions that restore perfusion over diagnostic measures and slow or inadequate routes of hydration.

Question 12

A 70-year-old client is 1 day post bowel resection and now has a new fever and tachycardia. Findings: temperature 38.8°C, heart rate 124/min, blood pressure 98/60 mm Hg, respiratory rate 22/min, oxygen saturation 94% on room air; abdomen is tender; white blood cell count 18,100/mm³ (4,500–11,000). What is the PRIORITY nursing action?

  1. Encourage coughing and deep breathing and assist with ambulation to prevent postoperative atelectasis
  2. Assess for sepsis and notify the provider of possible infection and hemodynamic changes (correct answer)
  3. Administer the prescribed acetaminophen and reassess temperature and heart rate in one hour
  4. Delegate intake and output documentation to unlicensed assistive personnel while continuing hourly monitoring
Explanation: The correct priority is to assess for sepsis and notify the provider of possible infection and hemodynamic changes. One day after a bowel resection, this client has new fever, tachycardia, hypotension, a tender abdomen, and an elevated white blood cell count — a constellation that strongly suggests early sepsis. Prompt recognition and escalation are critical because sepsis can progress to shock quickly, and early antimicrobial and hemodynamic intervention improves outcomes. Encouraging coughing, deep breathing, and ambulation targets postoperative atelectasis; while a reasonable preventive measure, it does not explain or treat the fever, low blood pressure, or abdominal tenderness. Administering acetaminophen treats the fever symptomatically and delays investigating the underlying infection; reassessing temperature in an hour loses valuable time. Delegating intake and output documentation to unlicensed assistive personnel is a clerical task that responds to none of the acute findings, so it is the lowest priority. When sepsis is suspected, escalate: assess and communicate urgent findings before treating symptoms or delegating documentation.

Question 13

A 79-year-old long-term care resident with a history of heart failure is febrile and increasingly short of breath. Findings: temperature 38.5°C, heart rate 120/min, blood pressure 88/54 mm Hg, respiratory rate 28/min, oxygen saturation 90% on room air; lung sounds have crackles at the bases; lactate 4.0 mmol/L (0.5–2.0). What is the PRIORITY nursing action?

  1. Administer an intravenous fluid bolus slowly while observing for crackles, to avoid fluid overload
  2. Delegate frequent repositioning and skin care to unlicensed assistive personnel once vital signs stabilize
  3. Obtain a daily weight at the same time each morning and compare it with baseline
  4. Apply supplemental oxygen and assess airway and breathing while preparing for sepsis interventions (correct answer)
Explanation: The correct priority is to apply supplemental oxygen and assess airway and breathing while preparing for sepsis interventions. This patient has hypoxemia on room air, tachypnea, crackles, and signs of sepsis with elevated lactate; the immediate threat is respiratory failure, so ABCs come before any other intervention. Starting the oxygen and evaluating airway and breathing directly treats the most urgent problem and positions you to act on the sepsis. Administering a slow IV fluid bolus while watching for crackles acknowledges heart failure but is not the first action; fluids need to be considered, but airway and oxygenation come first. Delegating repositioning and skin care after vital signs stabilize is a needed but nonurgent task and does not address the crisis. Obtaining a daily weight at the same time each morning is useful chronic heart-failure monitoring, not an emergency response, and would not improve the current hypoxia or shock. Thus, by prioritization, the only choice that immediately protects breathing and gives oxygen while mobilizing sepsis care is the keyed action.

Question 14

A 56-year-old client in the emergency department has suspected sepsis from a kidney infection. Findings: temperature 39.0°C, heart rate 124/min, blood pressure 86/48 mm Hg, respiratory rate 24/min, oxygen saturation 95% on room air; lactate 4.2 mmol/L (0.5–2.0). The provider writes orders. The nurse should QUESTION which order in this situation?

  1. Administer broad-spectrum intravenous antibiotics within 1 hour
  2. Infuse isotonic crystalloid bolus for hypotension per protocol
  3. Obtain blood cultures prior to antibiotic administration
  4. Give an oral bowel preparation solution to prevent constipation (correct answer)
Explanation: This question tests recognition and prioritization in sepsis orders from kidney infection. The priority framework is safety, questioning irrelevant or harmful orders. Giving an oral bowel preparation solution to prevent constipation is questionable as it is unrelated to sepsis management and may worsen dehydration. Administering antibiotics within 1 hour, infusing crystalloid bolus, and obtaining blood cultures are appropriate per sepsis guidelines. In sepsis, focus on infection and hemodynamics, not bowel prep. The decision-making principle ensures order relevance. A generalizable prioritization strategy is to challenge non-essential orders in acute sepsis using safety frameworks.

Question 15

A 60-year-old client is in the emergency department with suspected septic shock. Findings: temperature 38.8°C, heart rate 128/min, blood pressure 82/46 mm Hg, respiratory rate 28/min, oxygen saturation 93% on room air; urine output is minimal. Which intervention should be implemented IMMEDIATELY?

  1. Insert an indwelling urinary catheter to monitor hourly urine output throughout this clinical emergency.
  2. Delegate starting peripheral IV access to an experienced unlicensed assistive personnel while the nurse obtains blood cultures.
  3. Obtain a complete head-to-toe assessment and vital signs before making treatment decisions with the team.
  4. Begin rapid isotonic fluid resuscitation while preparing to obtain cultures and administer antibiotics. (correct answer)
Explanation: The client's temperature, heart rate, blood pressure, respiratory rate, and minimal urine output indicate septic shock. The immediate priority is to restore tissue perfusion by beginning rapid isotonic fluid resuscitation while simultaneously preparing to obtain cultures and administer antibiotics. Inserting an indwelling urinary catheter is helpful later for monitoring output, but it does not treat the shock or improve perfusion. Delegating IV access to an unlicensed assistive personnel is unsafe because starting an IV is an invasive, licensed nursing act that cannot be delegated to the UAP. Completing a full head-to-toe assessment before treatment decisions delays the urgent fluid and antibiotic therapy; assessment should not be sequenced before initial resuscitation in a patient with shock. Therefore, the correct immediate intervention is the one that starts with rapid isotonic fluid resuscitation, not monitoring, delegation, or assessment-first.

Question 16

A 59-year-old client presents to the emergency department with shortness of breath and productive cough for 4 days. History includes chronic obstructive pulmonary disease. Current findings: temperature 38.7°C, heart rate 132/min, blood pressure 84/48 mm Hg, respiratory rate 30/min, oxygen saturation 88% on room air, lactate 5.0 mmol/L (0.5–2.0). What is the PRIORITY nursing action for this client?

  1. Obtain a sputum specimen for culture and sensitivity before administering the first dose of prescribed antibiotics
  2. Place the client on high-flow oxygen and prepare for possible advanced airway support (correct answer)
  3. Administer the prescribed bronchodilator nebulizer treatment to relieve bronchospasm and improve airflow
  4. Ask the client to rate current pain on a 0-10 scale and document the response
Explanation: The client has signs of septic shock (hypotension, tachycardia, tachypnea, elevated lactate) with hypoxemia on room air. In this situation, the priority is airway and breathing: high-flow oxygen raises oxygen delivery, and preparing for possible advanced airway support is essential if the client cannot maintain oxygenation. Obtaining a sputum specimen before antibiotics is a correct infection-control step, but it comes after stabilizing oxygenation and does not address the immediate threat. A bronchodilator may improve airflow in COPD, but it does not correct the hypoxemia or shock physiology and is not the first priority. Asking for a pain rating is not urgent here; the client has no pain complaint and the immediate danger is respiratory failure. Use the ABC framework: secure airway and breathing before diagnostic, symptomatic, or comfort measures.

Question 17

A 74-year-old long-term care resident with a pressure injury is newly febrile and weak. Findings: temperature 38.7°C, heart rate 114/min, blood pressure 92/50 mm Hg, respiratory rate 22/min, oxygen saturation 96% on room air; wound has foul odor; white blood cell count 16,000/mm³ (4,500–11,000), lactate 3.4 mmol/L (0.5–2.0). What is the PRIORITY nursing action?

  1. Measure and stage the pressure injury and update the care plan
  2. Initiate sepsis screening, obtain intravenous access, and begin isotonic fluids per protocol (correct answer)
  3. Administer prescribed topical antimicrobial dressing to the wound bed
  4. Delegate a full bed bath and linen change to unlicensed assistive personnel
Explanation: This question tests recognition and prioritization in sepsis from pressure injury. The priority framework is the ABCs, focusing on circulation due to hypotension. Initiating sepsis screening, obtaining intravenous access, and beginning isotonic fluids per protocol is the highest priority to address instability. Measuring the injury, administering topical antimicrobial, and delegating a bath are lower priority as wound assessment, local treatment, and hygiene follow resuscitation. In chronic wound sepsis, systemic stabilization is key. The decision-making principle integrates screening with action. A generalizable prioritization strategy is to screen and resuscitate concurrently in suspected sepsis using ABCs.

Question 18

A 65-year-old client with suspected septic shock is in the emergency department. Findings: temperature 39.0°C, heart rate 130/min, blood pressure 80/44 mm Hg, respiratory rate 30/min, oxygen saturation 91% on room air; the client is pale and diaphoretic. Which intervention should be implemented IMMEDIATELY?

  1. Delegate collection of a stool sample for occult blood to unlicensed assistive personnel
  2. Obtain a complete health history including allergies and home medications
  3. Teach the client to use slow deep breathing to reduce anxiety
  4. Insert two large-bore intravenous catheters and start rapid isotonic fluid infusion (correct answer)
Explanation: This question tests recognition and prioritization in septic shock. The priority framework is the ABCs, focusing on circulation due to hypotension and diaphoresis. Inserting two large-bore intravenous catheters and starting rapid isotonic fluid infusion is the highest priority to restore volume. Obtaining a health history, teaching breathing, and delegating a stool sample are lower priority as history, anxiety management, and non-urgent tasks follow resuscitation. In septic shock, rapid fluids are essential for perfusion. The decision-making principle prioritizes circulatory stabilization. A generalizable prioritization strategy is to secure access and infuse fluids immediately in shock using ABCs.

Question 19

A 6-year-old child is brought to the emergency department with a 1-day history of vomiting and fever; the parent reports the child has been "breathing fast" and is very sleepy. Current findings: temperature 39.66C (103.36F), heart rate 152/min, respiratory rate 40/min with nasal flaring, blood pressure 84/46 mm Hg, capillary refill 5 seconds, oxygen saturation 90% on room air. Which intervention should be implemented IMMEDIATELY?

  1. Start oxygen therapy and prepare for rapid intravenous access for isotonic fluid bolus per protocol (correct answer)
  2. Obtain a detailed history of recent sick contacts and immunization status
  3. Administer oral rehydration solution in small, frequent sips
  4. Delegate to assistive personnel to obtain a weight and measure intake and output
Explanation: This question tests recognition and prioritization in pediatric septic shock. The priority framework combines ABCs with pediatric-specific considerations for compensated versus decompensated shock. The correct answer A (oxygen therapy and IV access for fluid bolus) is the highest priority because the child shows signs of decompensated shock (hypotension for age, prolonged capillary refill, altered mental status, hypoxemia) requiring immediate intervention. Option B (obtaining history) delays critical treatment; option C (oral rehydration) is inappropriate for a child in shock who needs rapid IV resuscitation; option D (weight and I&O) is important but not immediately life-saving. In pediatric septic shock, children can compensate until late stages, and hypotension represents decompensation requiring immediate aggressive intervention. The generalizable strategy is: in pediatric patients with hypotension, tachycardia, and signs of poor perfusion, immediately address both oxygenation and circulation simultaneously, as children in decompensated shock deteriorate rapidly without prompt intervention.

Question 20

A 62-year-old client arrives in the emergency department with a 2-day history of dysuria and fever; the client is pale and diaphoretic, confused, and reports chills. Current findings: temperature 39.26C (102.66F), heart rate 128/min, respiratory rate 28/min, blood pressure 82/46 mm Hg, oxygen saturation 92% on room air, lactate 4.8 mmol/L (reference 0.52.2), white blood cell count 18,500/mm (reference 4,50011,000). Which intervention should be implemented IMMEDIATELY?

  1. Obtain a clean-catch urine specimen for culture and sensitivity
  2. Administer a 30 mL/kg isotonic crystalloid bolus via large-bore intravenous access (correct answer)
  3. Delegate to unlicensed assistive personnel to obtain a full set of vital signs every 15 minutes
  4. Administer acetaminophen for fever reduction
Explanation: This question tests recognition and prioritization in sepsis and septic shock management. The priority framework here is ABCs (Airway, Breathing, Circulation), with circulation being the immediate concern given the severe hypotension (82/46 mm Hg). The correct answer B (administer 30 mL/kg isotonic crystalloid bolus) is the highest priority because the patient shows clear signs of septic shock with hypotension, tachycardia, elevated lactate, and altered mental status, requiring immediate fluid resuscitation to restore tissue perfusion. Option A (urine culture) is important for diagnosis but not immediately life-saving; option C (vital signs monitoring) is important but doesn't address the immediate circulatory crisis; option D (acetaminophen) addresses fever but not the life-threatening hypoperfusion. In septic shock, the first hour is critical - immediate fluid resuscitation takes precedence over diagnostic procedures or comfort measures. The generalizable principle is: when recognizing septic shock (hypotension + signs of infection + organ dysfunction), immediately address circulation with aggressive fluid resuscitation before pursuing diagnostics or other interventions.