Nclexrn Flashcards: Sepsis And Shock Recognition And Priorities

What this deck covers

This deck focuses on Sepsis And Shock Recognition And Priorities, giving you a quick way to review the definitions, rules, and examples that matter most for Nclexrn.

How to use these flashcards

Work through these flashcards in short sessions. Try to answer each prompt before flipping the card, then revisit any cards you miss until the explanation feels automatic.

Flashcard 1: What bedside finding best indicates poor tissue perfusion in shock?

Answer: Altered mental status. It reflects cerebral hypoperfusion due to inadequate oxygen delivery, signaling systemic tissue compromise in shock states.

Flashcard 2: Which intervention is contraindicated as the first action in cardiogenic shock with pulmonary edema?

Answer: Large-volume rapid fluid bolus. Excessive fluids exacerbate pulmonary congestion and impair cardiac output in volume-overloaded cardiogenic shock.

Flashcard 3: What mean arterial pressure (MAP) target is commonly used in septic shock resuscitation?

Answer: Target MAP = 65 mm Hg. This threshold ensures adequate organ perfusion, as lower values increase risk of organ failure in shock resuscitation.

Flashcard 4: Which shock type typically presents with warm, flushed skin and bounding pulses early on?

Answer: Distributive shock (septic shock). Vasodilation in distributive shock causes hyperdynamic circulation, leading to these early clinical manifestations before decompensation.

Flashcard 5: Which lab marker is commonly used to assess tissue hypoperfusion in sepsis?

Answer: Serum lactate. Elevated levels indicate anaerobic metabolism from tissue hypoperfusion, guiding resuscitation and prognosis in sepsis.

Flashcard 6: What is the priority intervention for suspected hypovolemic shock from hemorrhage?

Answer: Control bleeding and give rapid isotonic fluids and blood products as indicated. Stopping hemorrhage and restoring volume are essential to prevent further hypoperfusion and organ damage in hypovolemic shock.

Flashcard 7: Which finding most strongly suggests cardiogenic shock rather than septic shock?

Answer: Pulmonary edema with hypotension and signs of poor cardiac output. These indicate pump failure with fluid overload, distinguishing it from vasodilatory hypotension in septic shock.

Flashcard 8: What is the recommended timing goal for starting IV antibiotics in suspected sepsis?

Answer: Administer broad-spectrum antibiotics within $1$ hour of recognition. Timely administration reduces mortality by rapidly targeting the infectious source in sepsis management guidelines.

Flashcard 9: What set of findings most strongly suggests early sepsis in an adult?

Answer: Suspected infection plus fever or hypothermia, tachycardia, tachypnea, altered mentation. These signs reflect systemic inflammatory response syndrome (SIRS) criteria combined with infection, indicating potential organ dysfunction in early sepsis.

Flashcard 10: What is septic shock defined as in clinical terms?

Answer: Sepsis with persistent hypotension needing vasopressors and elevated lactate despite fluids. This definition from Sepsis-3 criteria identifies severe hypoperfusion and organ dysfunction requiring aggressive intervention beyond fluids alone.

Flashcard 11: Which urine output level is used as a minimum perfusion goal in shock resuscitation?

Answer: Urine output = 0.5 mL/kg/hr. This rate indicates adequate renal perfusion and glomerular filtration, serving as a key goal in monitoring shock resuscitation efficacy.

Flashcard 12: What is the priority medication for anaphylactic shock?

Answer: Intramuscular epinephrine. It rapidly reverses vasodilation and bronchoconstriction, stabilizing hemodynamics in anaphylaxis-induced distributive shock.

Flashcard 13: Which action should occur first when sepsis is suspected: obtain cultures or start antibiotics?

Answer: Obtain cultures first if it does not delay antibiotics; then start broad-spectrum antibiotics. Cultures preserve microbial identification for targeted therapy, but antibiotics must not be delayed to prevent progression of infection.

Flashcard 14: What lactate level is generally considered abnormal and concerning in suspected sepsis?

Answer: Lactate = 2 mmol/L is abnormal; higher levels indicate worse hypoperfusion. Levels above this threshold correlate with increased mortality and need for aggressive resuscitation in hypoperfused states.

Flashcard 15: Which oxygenation intervention is appropriate first for a septic patient with increased work of breathing?

Answer: Apply supplemental oxygen to maintain adequate oxygenation and reduce work of breathing. It supports oxygen delivery and eases respiratory effort, preventing fatigue and deterioration in septic patients.

Flashcard 16: What is the correct sequence when starting a sepsis workup without delaying treatment?

Answer: Oxygen, IV access, lactate, cultures, fluids, then antibiotics within $1$ hour. This order aligns with the Surviving Sepsis Campaign hour-1 bundle to stabilize and treat without delays in critical interventions.

Flashcard 17: What is the priority infection-control nursing action when sepsis is suspected?

Answer: Perform hand hygiene and implement appropriate isolation/standard precautions immediately. Prevents transmission of potential pathogens, protecting patients and staff in accordance with infection control standards.

Flashcard 18: What is the earliest, most sensitive sign of shock in an adult patient?

Answer: Tachycardia. It represents a compensatory response to decreased stroke volume or hypovolemia, appearing before hypotension in shock progression.

Flashcard 19: Which patient requires the most urgent evaluation for possible sepsis on a medical-surgical unit?

Answer: Patient with suspected infection plus new confusion and hypotension. New organ dysfunction like confusion and hypotension signals severe sepsis requiring immediate intervention to prevent shock.

Flashcard 20: What is the priority nursing action when a patient on vasopressors has a dropping blood pressure?

Answer: Assess airway and perfusion, verify infusion and IV patency, then titrate per protocol. Systematic assessment ensures patient stability and proper drug delivery before adjusting therapy to avoid errors in shock management.

Flashcard 21: Which assessment best helps identify progression from sepsis to septic shock at the bedside?

Answer: Persistent hypotension and rising lactate despite fluid resuscitation. These signs indicate refractory hypoperfusion and need for vasopressors, marking the transition to septic shock per clinical definitions.

Flashcard 22: Which shock type is most associated with cool, clammy skin and narrow pulse pressure?

Answer: Hypovolemic shock. Volume depletion triggers compensatory vasoconstriction, resulting in these signs of reduced peripheral perfusion.

Flashcard 23: What is the most important immediate nursing priority when sepsis is suspected?

Answer: Initiate sepsis protocol and support airway, breathing, and circulation. Addresses immediate life-threatening instability by prioritizing ABCs and activating evidence-based sepsis management to improve outcomes.

Flashcard 24: Which vasopressor is first-line for septic shock after adequate fluid resuscitation?

Answer: Norepinephrine. It effectively increases vascular tone and maintains organ perfusion with fewer arrhythmias compared to alternatives in septic shock.

Flashcard 25: What is the initial crystalloid bolus for adult sepsis-induced hypoperfusion or shock?

Answer: Give $30$ mL/kg isotonic crystalloid rapidly. This volume restores intravascular fluid to improve perfusion in hypoperfused states per Surviving Sepsis Campaign guidelines.