Next Generation NCLEX
Sample Test Questions
Case Study: Home Hospice
Home Hospice: Question 1
Client History: 84-year-old client diagnosed
with stage 4 lung cancer with metastasis to
the brain and liver. Client lives with his
daughter and her family, who are his main
caregivers at home. Client’s advance
directive states that he does not want CPR,
intravenous fluids, antibiotics, a feeding tube,
or hospitalization at the end of life. Daughter
is his health care power of attorney.
Nurses Notes: Client sitting in recliner. Awake
and confused, and insists he needs to go see
his wife, who has been deceased for 15
years. Daughter states is very concerned
because the client has become more agitated
over the past two days and is not sleeping at
night. Client’s skin is hot and pale, oral
mucosa dry. Breath sounds diminished
throughout with coarse rhonchi on the right.
Productive cough with large amounts of thick,
white sputum. Client reports “terrible” pain in
his back that is not being relieved” by his
current pain medication. Taking sips of water,
but refuses food and reports having no
appetite.
Vital signs:
BP 108/60
HR 88 irregular
RR 18
SpO2 92% on
2L O2/NC
Temp 100.8°F
(38.22°C)
Q1: Highlight the information which is most
important for the nurse to consider when
providing care for this client.
Home Hospice: Question 2
Client History: 84-year-old client diagnosed
with stage 4 lung cancer with metastasis to
the brain and liver. Client lives with his
daughter and her family, who are his main
caregivers at home. Client’s advance
directive states that he does not want CPR,
intravenous fluids, antibiotics, a feeding tube,
or hospitalization at the end of life. Daughter
is his health care power of attorney.
Nurses Notes: Client sitting in recliner. Awake
and confused, and insists he needs to go see
his wife, who has been deceased for 15
years. Daughter states is very concerned
because the client has become more agitated
over the past two days and is not sleeping at
night. Client’s skin is hot and pale, oral
mucosa dry. Breath sounds diminished
throughout with coarse rhonchi on the right.
Productive cough with large amounts of thick,
white sputum. Client reports “terrible” pain in
his back that is not being relieved” by his
current pain medication. Taking sips of water,
but refuses food and reports having no
appetite.
Vital signs:
BP 108/60
HR 88 irregular
RR 18
SpO2 92% on
2L O2/NC
Temp 100.8°F
(38.22°C)
Q2: Indicate the 4 assessment findings that
require immediate intervention.
Assessment Findings
❏
BP 108/60, HR 88 and irregular.
❏
Client is awake and confused.
❏
Caregiver reports increased agitation.
❏
Not sleeping at night
❏
Productive cough.
❏
Pain unrelieved by medication.
❏
Decreased oral intake.
Home Hospice: Question 3
Client History: 84-year-old client diagnosed
with stage 4 lung cancer with metastasis to
the brain and liver. Client lives with his
daughter and her family, who are his main
caregivers at home. Client’s advance
directive states that he does not want CPR,
intravenous fluids, antibiotics, a feeding tube,
or hospitalization at the end of life. Daughter
is his health care power of attorney.
Nurses Notes: Client sitting in recliner. Awake
and confused, and insists he needs to go see
his wife, who has been deceased for 15
years. Daughter states is very concerned
because the client has become more agitated
over the past two days and is not sleeping at
night. Client’s skin is hot and pale, oral
mucosa dry. Breath sounds diminished
throughout with coarse rhonchi on the right.
Productive cough with large amounts of thick,
white sputum. Client reports “terrible” pain in
his back that is not being relieved” by his
current pain medication. Taking sips of water,
but refuses food and reports having no
appetite.
Vital signs:
BP 108/60
HR 88 irregular
RR 18
SpO2 92% on
2L O2/NC
Temp 100.8°F
(38.22°C)
Q3: The nurse completes the client
assessment and immediately
________________________
[choices: 1. Notifies the HCP of the client’s
vital signs 2. Prepares to suction the client
3. Reviews the frequency and amount of pain
medication given 4. Encourages the client to
increase oral intake] and informs the
caregiver that ______________________
[choices: 1. The client will likely expire soon.
2. Agitation can be due to unrelieved pain. 3.
There is little that can be done for the client.
4. The client will need to be heavily sedated.
Home Hospice: Question 4
Client History: 84-year-old client diagnosed
with stage 4 lung cancer with metastasis to
the brain and liver. Client lives with his
daughter and her family, who are his main
caregivers at home. Client’s advance
directive states that he does not want CPR,
intravenous fluids, antibiotics, a feeding tube
or hospitalization at the end of life. Daughter
is his health care power of attorney.
Nurses Notes: Client sitting in recliner. Awake
and confused, and insists he needs to go see
his wife, who has been deceased for 15
years. Daughter states is very concerned
because the client has become more agitated
over the past two days and is not sleeping at
night. Client’s skin is hot and pale, oral
mucosa dry. Breath sounds diminished
throughout with coarse rhonchi on the right.
Productive cough with large amounts of thick,
white sputum. Client reports “terrible” pain in
his back that is not being relieved” by his
current pain medication. Taking sips of water,
but refuses food and reports having no
appetite.
Vital signs:
BP 108/60
HR 88 irregular
RR 18
SpO2 92% on
2L O2/NC
Temp 100.8°F
(38.22°C)
Q4: Drag words from the choices below to fill
in each blank found in the following sentence.
The best achievable outcomes for this client
would be to _________________________
and __________________________.
Options
increase fluid intake to 1200 mL/day
have optimal pain relief
be alert and oriented to person, place, time, and
situation
have improved sleep
have clear bilateral breath sounds
maintain SpO2 > 98% on 2L/NC
Home Hospice: Question 5
Client History: 84-year-old client diagnosed
with stage 4 lung cancer with metastasis to
the brain and liver. Client lives with his
daughter and her family, who are his main
caregivers at home. Client’s advance
directive states that he does not want CPR,
intravenous fluids, antibiotics, a feeding tube,
or hospitalization at the end of life. Daughter
is his health care power of attorney.
Nurses Notes: Client sitting in recliner. Awake
and confused, and insists he needs to go see
his wife, who has been deceased for 15
years. Daughter states is very concerned
because the client has become more agitated
over the past two days and is not sleeping at
night. Client’s skin is hot and pale, oral
mucosa dry. Breath sounds diminished
throughout with coarse rhonchi on the right.
Productive cough with large amounts of thick,
white sputum. Client reports “terrible” pain in
his back that is not being relieved” by his
current pain medication. Taking sips of water,
but refuses food and reports having no
appetite.
Vital signs:
BP 108/60
HR 88 irregular
RR 18
SpO2 92% on
2L O2/NC
Temp 100.8°F
(38.22°C)
Q5: The client’s daughter is concerned about
the fever and the fact the client is not eating
or drinking. She requests IV fluids and
antibiotics be given at once. Indicate which
nursing interventions are most appropriate for
the client.
❏ Request an antibiotic from the HCP.
❏ Review the client’s advance directive
with the caregiver.
❏ Instruct the caregiver to provide oral
care every 4 hours.
❏ Provide information to the family about
music or massage therapy for the
client.
❏ Provide oral suction at the bedside.
❏ Sponge the client with cold water.
❏ Monitor the client’s urine output every
1 hour.
❏ Begin a peripheral IV of NS at 100
mL/hr.
❏ Teach the daughter about signs and
symptoms at end of life.
❏ Ask the daughter if she would like to
pray.
Home Hospice: Question 6
Client History: 84-year-old client diagnosed
with stage 4 lung cancer with metastasis to
the brain and liver. Client lives with his
daughter and her family, who are his main
caregivers at home. Client’s advance
directive states that he does not want CPR,
intravenous fluids, antibiotics, a feeding tube,
or hospitalization at the end of life. Daughter
is his health care power of attorney.
Nurses Notes: Client sitting in recliner. Awake
and confused, and insists he needs to go see
his wife, who has been deceased for 15
years. Daughter states is very concerned
because the client has become more agitated
over the past two days and is not sleeping at
night. Client’s skin is hot and pale, oral
mucosa dry. Breath sounds diminished
throughout with coarse rhonchi on the right.
Productive cough with large amounts of thick,
white sputum. Client reports “terrible” pain in
his back that is not being relieved” by his
current pain medication. Taking sips of water,
but refuses food and reports having no
appetite.
Vital signs:
BP 108/60
HR 88 irregular
RR 18
SpO2 92% on
2L O2/NC
Temp 100.8°F
(38.22°C)
Q6: At the end of the visit, the nurse reevaluates the client. Indicate if the
assessment findings are improved, show no
change, or show the client has declined.
Client
Response
Respirations
irregular with
periods of
apnea.
Client resting in
recliner. RR 12,
regular.
Oral mucous
membranes dry.
Axillary temp
102°F (38.9°C),
client shivering.
Client calm, not
agitated.
Grimaces with
movement.
Coarse rhonchi
bilaterally.
Crackles in
bases.
Productive
cough.
Improved
No
Change
Declined
Case Study: Secondary Cushing Syndrome
Secondary Cushing Syndrome: Question 1
Nurses Notes: 58-year-old client diagnosed
with severe systemic lupus erythematosus.
Three weeks ago she began to take
prednisone 20 mg po q am and 10 mg po q
pm to control flare up. Clinic appointment
today: client states, “I feel worse than I did
before I started taking prednisone. I have to
urinate all the time. I’ve gained 10 pounds
and I can’t sleep. I didn’t take the prednisone
this morning and I’m not going to take it
anymore.”
Vital Signs:
BP 170/92
HR 78
RR 18
oral T 99°F (37.2°C)
Laboratory Results:
Fasting Blood
Glucose
180 mg/dL (9.98 mmol/L)
Na
146 mEq/L (146 mmol/L)
K
2.8 mEq/L (2.8 mmol/L)
Cl
102 mEq/L (102 mmol/L)
Cr
Creatinine 0.8 mg/dL (70.74 µmol/L)
BUN
6 mg/dL (2.14 mmol/L)
Q1: Highlight the assessment findings which
place the client at highest risk for injury.
Secondary Cushing Syndrome: Question 2
Nurses Notes: 58-year-old client diagnosed
with severe systemic lupus erythematosus.
Three weeks ago she began to take
prednisone 20 mg po q am and 10 mg po q
pm to control flare up. Clinic appointment
today: client states, “I feel worse than I did
before I started taking prednisone. I have to
urinate all the time. I’ve gained 10 pounds
and I can’t sleep. I didn’t take the prednisone
this morning and I’m not going to take it
anymore.”
Vital Signs:
BP 170/92
HR 78
RR 18
oral T 99°F (37.2°C)
Laboratory Results:
Fasting Blood
Glucose
180 mg/dL (9.98 mmol/L)
Na
146 mEq/L (146 mmol/L)
K
2.8 mEq/L (2.8 mmol/L)
Cl
102 mEq/L (102 mmol/L)
Cr
Creatinine 0.8 mg/dL (70.74 µmol/L)
BUN
6 mg/dL (2.14 mmol/L)
Q2: Based on the client’s history and
assessment findings, the nurse understands
the client is at highest risk for
________________________ [choices:
secondary infection, diabetic ketoacidosis,
renal failure, fluid volume deficit] and
___________________________ [choices:
hyponatremia, cardiac dysrhythmia, pressure
injury, respiratory failure] .
Secondary Cushing Syndrome: Question 3
Nurses Notes: 58-year-old client diagnosed
with severe systemic lupus erythematosus.
Three weeks ago she began to take
prednisone 20 mg po q am and 10 mg po q
pm to control flare up. Clinic appointment
today: client states, “I feel worse than I did
before I started taking prednisone. I have to
urinate all the time. I’ve gained 10 pounds
and I can’t sleep. I didn’t take the prednisone
this morning and I’m not going to take it
anymore.”
Vital Signs:
BP 170/92
HR 78
RR 18
oral T 99°F (37.2°C)
Laboratory Results:
Fasting Blood
Glucose
180 mg/dL (9.98 mmol/L)
Na
146 mEq/L (146 mmol/L)
K
2.8 mEq/L (2.8 mmol/L)
Cl
102 mEq/L (102 mmol/L)
Cr
Creatinine 0.8 mg/dL (70.74 µmol/L)
BUN
6 mg/dL (2.14 mmol/L)
Q3: Prioritize the education provided to the client
as high priority, low priority, or contraindicated.
Education
Take
prednisone on
an empty
stomach
Never abruptly
stop
corticosteroids
Eat a diet low
in calcium and
potassium
See an eye
specialist
annually
Avoid contact
with
individuals
with colds
Report
polydipsia and
polyuria to
HCP
High
Priority
Low
Priority
Contraindicated
Secondary Cushing Syndrome: Question 4
Nurses Notes: 58-year-old client diagnosed
with severe systemic lupus erythematosus.
Three weeks ago she began to take
prednisone 20 mg po q am and 10 mg po q
pm to control flare up. Clinic appointment
today: client states, “I feel worse than I did
before I started taking prednisone. I have to
urinate all the time. I’ve gained 10 pounds
and I can’t sleep. I didn’t take the prednisone
this morning and I’m not going to take it
anymore.”
Vital Signs:
BP 170/92
HR 78
RR 18
oral T 99°F (37.2°C)
Laboratory Results:
Fasting Blood
Glucose
180 mg/dL (9.98 mmol/L)
Na
146 mEq/L (146 mmol/L)
K
2.8 mEq/L (2.8 mmol/L)
Cl
102 mEq/L (102 mmol/L)
Cr
Creatinine 0.8 mg/dL (70.74 µmol/L)
BUN
6 mg/dL (2.14 mmol/L)
Q4: Drag the correct statements from the
word list provided to complete the statement.
The nurse will determine if the client has any
reports of __________________________ or
________________________________
which could indicate further adverse effects of
corticosteroid treatment.
Word Choices
Mouth ulcers
Dark tarry stools
Constipation
Pain in the hips
Increased joint swelling
Butterfly rash
Eye dryness
Secondary Cushing Syndrome: Question 5
Nurses Notes: 58-year-old client diagnosed
with severe systemic lupus erythematosus.
Three weeks ago she began to take
prednisone 20 mg po q am and 10 mg po q
pm to control flare up. Clinic appointment
today: client states, “I feel worse than I did
before I started taking prednisone. I have to
urinate all the time. I’ve gained 10 pounds
and I can’t sleep. I didn’t take the prednisone
this morning and I’m not going to take it
anymore.”
Vital Signs:
BP 170/92
HR 78
RR 18
oral T 99°F (37.2°C)
Laboratory Results:
Fasting Blood
Glucose
180 mg/dL (9.98 mmol/L)
Na
146 mEq/L (146 mmol/L)
K
2.8 mEq/L (2.8 mmol/L)
Cl
102 mEq/L (102 mmol/L)
Cr
Creatinine 0.8 mg/dL (70.74 µmol/L)
BUN
6 mg/dL (2.14 mmol/L)
Q5: The nurse communicates assessment
findings to the health care provider and
receives several orders. Indicate the 3 orders
the nurse should perform immediately.
New HCP Orders:
❏ Obtain a 12-lead EKG.
❏ Determine the client’s risk for falls at
home.
❏ Teach the client to perform FSBG
monitoring at home.
❏ Obtain daily weights.
❏ Administer KCl 40 mEq po.
❏ Obtain a urine C/S.
Secondary Cushing Syndrome: Question 6
Nurses Notes: 58-year-old client diagnosed
with severe systemic lupus erythematosus.
Three weeks ago she began to take
prednisone 20 mg po q am and 10 mg po q
pm to control flare up. Clinic appointment
today: client states, “I feel worse than I did
before I started taking prednisone. I have to
urinate all the time. I’ve gained 10 pounds
and I can’t sleep. I didn’t take the prednisone
this morning and I’m not going to take it
anymore.”
Q6: The HCP places the client on a tapering
dose of prednisone over the following week,
with the client receiving prednisone 10 mg po
q am and 5 mg po q pm as a maintenance
dose. The client returns for a follow up clinic
appointment in one week.
Which assessment findings indicate the client
is reaching desired outcomes of treatment
and education?
Assessment Findings
Vital Signs:
BP 170/92
HR 78
❏
Joint pain rated as 1/10.
RR 18
oral T 99°F (37.2°C)
❏
The client has a round, puffy “moon” face.
❏
Weight gain of 10 lbs in 1 week.
❏
Client states, “I eat a banana every day.”
❏
Blood pressure 116/70.
❏
Moderate hirsutism.
Laboratory Results:
Fasting Blood
Glucose
180 mg/dL (9.98 mmol/L)
Na
146 mEq/L (146 mmol/L)
K
2.8 mEq/L (2.8 mmol/L)
❏
Client sleeps 7-8 hours at night.
Cl
102 mEq/L (102 mmol/L)
❏
Client reports black stools with foul odor.
❏
Client states, “I monitor my blood glucose
once a week.”
❏
Client has sunburn on skin of face and
arms.
Cr
Creatinine 0.8 mg/dL (70.74 µmol/L)
BUN
6 mg/dL (2.14 mmol/L)
Case Study: Septic Shock
Septic Shock: Question 1
Nurses Notes:
Report: 34-year-old client reports being sick with
influenza. Admitted to hospital two days ago with
a diagnosis of RLL pneumococcal pneumonia.
Previous night shift reports the client has been
awake, alert, and oriented through the evening.
Scattered rhonchi and a productive cough with
small amounts of yellow sputum. VSS. Client has
reported no appetite and has not slept well.
0800: Client restless and confused. Skin flushed
and hot. Client voiding approximately 400 mL per
shift, fine crackles in both bases, wheezes present
in right lung field.
Health Care Provider Orders:
O2 at 3L per nasal cannula, IV of 0.9 NS at 100
mL/hour
Levofloxacin 500 mg in 0.9% NS 100 mL IV every
24 hours
Albuterol per nebulizer every 6 hours
Methylprednisolone 125 mg IV every 6 hours
Vital Signs:
Measurement
0400
0800
Temp (oral)
99°F (37°C)
102°F (33.8°C)
HR
88
128
BP
116/78
82/56
RR
20
34
SpO2 on 3L/NC
94%
86%
Laboratory Results:
Lab
Result
Lab
Result
Glucose
144 mg/dL (8
mmol/L)
Ca
8.2 mg/dL (2.5
mmol/L)
Na
135 mEq/L
(135 mmol/L)
BUN
10 mg/dL (3.57
mmol/L)
Cl
96 mEq/L (96
mmol/L)
Cr
1.2 mg/dL (106.08
µmol/L)
K
3.2 mEq/L
(3.2 mmol/L)
WBC
16,000/mm3 (16 X
109/L)
Q1: Highlight the assessment findings which
should be reported to the healthcare provider.
Septic Shock: Question 2
Nurses Notes:
Report: 34-year-old client reports being sick with
influenza. Admitted to hospital two days ago with
a diagnosis of RLL pneumococcal pneumonia.
Previous night shift reports the client has been
awake, alert, and oriented through the evening.
Scattered rhonchi and a productive cough with
small amounts of yellow sputum. VSS. Client has
reported no appetite and has not slept well.
0800: Client restless and confused. Skin flushed
and hot. Client voiding approximately 400 mL per
shift, fine crackles in both bases, wheezes present
in right lung field.
Health Care Provider Orders:
O2 at 3L per nasal cannula, IV of 0.9 NS at 100
mL/hour
Levofloxacin 500 mg in 0.9% NS 100 mL IV every
24 hours
Albuterol per nebulizer every 6 hours
Methylprednisolone 125 mg IV every 6 hours
Vital Signs:
Measurement
0400
0800
Temp (oral)
99°F (37°C)
102°F (33.8°C)
HR
88
128
BP
116/78
82/56
RR
20
34
SpO2 on 3L/NC
94%
86%
Laboratory Results:
Lab
Result
Lab
Result
Glucose
144 mg/dL (8
mmol/L)
Ca
8.2 mg/dL (2.5
mmol/L)
Na
135 mEq/L
(135 mmol/L)
BUN
10 mg/dL (3.57
mmol/L)
Cl
96 mEq/L (96
mmol/L)
Cr
1.2 mg/dL (106.08
µmol/L)
K
3.2 mEq/L
(3.2 mmol/L)
WBC
16,000/mm3 (16 X
109/L)
Q2: Which 4 clinical findings and information
from the client’s history and current
assessment indicate this client is septic?
Client Findings
Glucose 144 mg/dL (8 mmol/L)
WBC 16,000/mm3 (16 X 109/L)
Productive cough
BP 82/56
Skin hot and dry
Cr 1.2 mg/dL (106.08 µmol/L)
Confusion
Diagnosis of pneumonia
Septic Shock: Question 3
Nurses Notes:
Report: 34-year-old client reports being sick with
influenza. Admitted to hospital two days ago with
a diagnosis of RLL pneumococcal pneumonia.
Previous night shift reports the client has been
awake, alert, and oriented through the evening.
Scattered rhonchi and a productive cough with
small amounts of yellow sputum. VSS. Client has
reported no appetite and has not slept well.
0800: Client restless and confused. Skin flushed
and hot. Client voiding approximately 400 mL per
shift, fine crackles in both bases, wheezes present
in right lung field.
Health Care Provider Orders:
O2 at 3L per nasal cannula, IV of 0.9 NS at 100
mL/hour
Levofloxacin 500 mg in 0.9% NS 100 mL IV every
24 hours
Albuterol per nebulizer every 6 hours
Methylprednisolone 125 mg IV every 6 hours
Vital Signs:
Measurement
0400
0800
Temp (oral)
99°F (37°C)
102°F (33.8°C)
HR
88
128
BP
116/78
82/56
RR
20
34
SpO2 on 3L/NC
94%
86%
Laboratory Results:
Lab
Result
Lab
Result
Glucose
144 mg/dL (8
mmol/L)
Ca
8.2 mg/dL (2.5
mmol/L)
Na
135 mEq/L
(135 mmol/L)
BUN
10 mg/dL (3.57
mmol/L)
Cl
96 mEq/L (96
mmol/L)
Cr
1.2 mg/dL (106.08
µmol/L)
K
3.2 mEq/L
(3.2 mmol/L)
WBC
16,000/mm3 (16 X
109/L)
Q3: The client is at greatest risk for
_________________________ [choices:
dehydration, uncontrolled pain, impaired
tissue perfusion, increased intracranial
pressure] as evidenced
by___________________________
[hyperglycemia and confusion, tachycardia
and hyperthermia, productive cough and
tachypnea, hypotension and elevated
creatinine].
Septic Shock: Question 4
Nurses Notes:
Report: 34-year-old client reports being sick with
influenza. Admitted to hospital two days ago with
a diagnosis of RLL pneumococcal pneumonia.
Previous night shift reports the client has been
awake, alert, and oriented through the evening.
Scattered rhonchi and a productive cough with
small amounts of yellow sputum. VSS. Client has
reported no appetite and has not slept well.
0800: Client restless and confused. Skin flushed
and hot. Client voiding approximately 400 mL per
shift, fine crackles in both bases, wheezes present
in right lung field.
Health Care Provider Orders:
O2 at 3L per nasal cannula, IV of 0.9 NS at 100
mL/hour
Levofloxacin 500 mg in 0.9% NS 100 mL IV every
24 hours
Albuterol per nebulizer every 6 hours
Methylprednisolone 125 mg IV every 6 hours
Vital Signs:
Measurement
0400
0800
Temp (oral)
99°F (37°C)
102°F (33.8°C)
HR
88
128
BP
116/78
82/56
RR
20
34
SpO2 on 3L/NC
94%
86%
Laboratory Results:
Lab
Result
Lab
Result
Glucose
144 mg/dL (8
mmol/L)
Ca
8.2 mg/dL (2.5
mmol/L)
Na
135 mEq/L
(135 mmol/L)
BUN
10 mg/dL (3.57
mmol/L)
Cl
96 mEq/L (96
mmol/L)
Cr
1.2 mg/dL (106.08
µmol/L)
K
3.2 mEq/L
(3.2 mmol/L)
WBC
16,000/mm3 (16 X
109/L)
Q4: Which HCP orders and nursing
interventions are indicated for the client?
Intervention
Obtain blood
cultures
Administer
acetaminophen
500 mg po
Obtain ABGs
Place the client
in
Trendelenburg
position
Assess urine
output hourly
Priority
Contraindicated
Septic Shock: Question 5
Nurses Notes:
Report: 34-year-old client reports being sick with
influenza. Admitted to hospital two days ago with
a diagnosis of RLL pneumococcal pneumonia.
Previous night shift reports the client has been
awake, alert, and oriented through the evening.
Scattered rhonchi and a productive cough with
small amounts of yellow sputum. VSS. Client has
reported no appetite and has not slept well.
0800: Client restless and confused. Skin flushed
and hot. Client voiding approximately 400 mL per
shift, fine crackles in both bases, wheezes present
in right lung field.
Health Care Provider Orders:
O2 at 3L per nasal cannula, IV of 0.9 NS at 100
mL/hour
Levofloxacin 500 mg in 0.9% NS 100 mL IV every
24 hours
Albuterol per nebulizer every 6 hours
Methylprednisolone 125 mg IV every 6 hours
Vital Signs:
Measurement
0400
0800
Temp (oral)
99°F (37°C)
102°F (33.8°C)
HR
88
128
BP
116/78
82/56
RR
20
34
SpO2 on 3L/NC
94%
86%
Laboratory Results:
Lab
Result
Lab
Result
Glucose
144 mg/dL (8
mmol/L)
Ca
8.2 mg/dL (2.5
mmol/L)
Na
135 mEq/L
(135 mmol/L)
BUN
10 mg/dL (3.57
mmol/L)
Cl
96 mEq/L (96
mmol/L)
Cr
1.2 mg/dL (106.08
µmol/L)
K
3.2 mEq/L
(3.2 mmol/L)
WBC
16,000/mm3 (16 X
109/L)
Q5: The nurse reviews the following ABG
results for the client. The client is on oxygen
at 3L/nasal cannula and the respiratory rate is
30/minute. The SpO2 is 86%.
Arterial Blood Gases
on 3L O2/NC
pH
7.36
PaO2
82
PCO2
30
HCO3
19
Based on these ABG results the nurse knows
the client is in ____________________
[Choices: 1. Compensated metabolic acidosis
2. Metabolic alkalosis 3. Compensated
respiratory acidosis 4. Respiratory alkalosis]
and is in danger of
______________________ [Choices: 1.
Hypoventilation and hypercapnea 2. Oxygen
toxicity and kidney failure 3. Hypoxemia and
respiratory failure 4. Hyperventilation and
central nervous system depression].
Septic Shock: Question 6
Nurses Notes:
Report: 34-year-old client reports being sick with
influenza. Admitted to hospital two days ago with
a diagnosis of RLL pneumococcal pneumonia.
Previous night shift reports the client has been
awake, alert, and oriented through the evening.
Scattered rhonchi and a productive cough with
small amounts of yellow sputum. VSS. Client has
reported no appetite and has not slept well.
0800: Client restless and confused. Skin flushed
and hot. Client voiding approximately 400 mL per
shift, fine crackles in both bases, wheezes present
in right lung field.
Health Care Provider Orders:
O2 at 3L per nasal cannula, IV of 0.9 NS at 100
mL/hour
Levofloxacin 500 mg in 0.9% NS 100 mL IV every
24 hours
Albuterol per nebulizer every 6 hours
Methylprednisolone 125 mg IV every 6 hours
Vital Signs:
Measurement
0400
0800
Temp (oral)
99°F (37°C)
102°F (33.8°C)
HR
88
128
BP
116/78
82/56
RR
20
34
SpO2 on 3L/NC
94%
86%
Laboratory Results:
Lab
Result
Lab
Result
Glucose
144 mg/dL (8
mmol/L)
Ca
8.2 mg/dL (2.5
mmol/L)
Na
135 mEq/L
(135 mmol/L)
BUN
10 mg/dL (3.57
mmol/L)
Cl
96 mEq/L (96
mmol/L)
Cr
1.2 mg/dL (106.08
µmol/L)
K
3.2 mEq/L
(3.2 mmol/L)
WBC
16,000/mm3 (16 X
109/L)
Q6: The client is intubated and placed on a
mechanical ventilator. The client is also
heavily sedated to better control the
respiratory rate and effort. The client
continues to receive fluids, antibiotics, and
medications to support blood pressure. The
client is reassessed at 1400. Choose findings
which indicate the interventions for this client
have been effective or ineffective.
Assessment
1400
BP 110/62
ABG PaO2
110%
UOP 10
mL/hour
WBC 12,000
mm3 (12 X
109/L)
Creatinine 2.8
mg/dL (247.58
µmol/L)
Effective
Ineffective