Early sepsis recognition and bundle-based management are high-stakes med-surg skills the CMSRN emphasizes. Drill the SIRS, lactate, and resuscitation scenarios below, each with a full rationale.
Question 1
A patient from a tuberculosis-endemic region presents with hemoptysis and night sweats. The unit has one negative-pressure room occupied. What is the priority action before room availability?
- A) A) Place a surgical mask on the patient in a private room✓
- B) B) Transfer the patient to an airborne infection isolation room
- C) C) Initiate droplet precautions with staff eye protection
- D) D) Use portable HEPA filters in a shared ward space
Show rationale
Hemoptysis and night sweats suggest active TB. While awaiting a negative-pressure room, CDC recommends masking the patient in a private room to reduce dispersal. Option B is ideal but unavailable. Option C doesn't address airborne transmission. Option D is adjunctive but insufficient alone. TB-endemic exposure and symptoms necessitate immediate source control via masking.
Question 2
A neutropenic patient with a PICC line has a transparent dressing changed. Which technique aligns with evidence-based practice?
- A) A) Cleanse with povidone-iodine using 30-second circular strokes
- B) B) Apply chlorhexidine gluconate using back-and-forth strokes for 30 seconds✓
- C) C) Scrub with 70% isopropyl alcohol using friction for 15 seconds
- D) D) Wipe with hydrogen peroxide followed by saline using concentric circles
Show rationale
CDC/SHEA guidelines recommend chlorhexidine for PICC care in neutropenic patients due to superior antimicrobial efficacy. Back-and-forth mechanical cleansing removes biofilm. Povidone-iodine (A) is inferior to chlorhexidine. Alcohol (C) lacks residual activity. Hydrogen peroxide (D) damages skin integrity. The 30-second friction ensures adequate antisepsis, critical for immunocompromised patients.
Question 3
A diabetic patient with stage 3 CKD reports to a post-hurricane shelter with 3 days of vomiting and glucose readings of 380 mg/dL. The shelter has limited IV supplies and no dialysis access. Which action best addresses imminent risks?
- A) A) Administer subcutaneous insulin and oral rehydration solution
- B) B) Start a normal saline IV bolus and contact medical control for transfer✓
- C) C) Provide antiemetics and monitor urine output hourly
- D) D) Withhold all medications until electrolytes are checked
Show rationale
Hyperglycemia with vomiting and CKD creates imminent risks of HHS and acute renal injury, requiring IV fluids and advanced care. Option B prioritizes stabilization and transfer. Option A is unsafe: oral rehydration fails with vomiting, and CKD increases insulin complication risks. Option C delays critical fluid resuscitation. Option D neglects acute metabolic crisis management. Disaster nursing standards mandate resource-efficient stabilization for transfer when on-site care is inadequate.
Question 4
When initiating the sepsis bundle for a febrile neutropenic patient with acute leukemia, which action aligns with Surviving Sepsis Campaign guidelines within the first hour?
- A) A) Administering broad-spectrum antibiotics after obtaining cultures
- B) B) Obtaining lactate levels using a point-of-care testing device
- C) C) Starting IV fluid resuscitation with 30mL/kg crystalloids
- D) D) Drawing blood cultures prior to antibiotic administration✓
Show rationale
D is correct: Sepsis bundles mandate cultures before antibiotics to avoid false negatives, especially in immunocompromised patients. A is incorrect: Antibiotics must follow—not precede—cultures. B is incorrect: Lactate guides therapy but isn't time-sensitive for culture timing. C is incorrect: Fluids follow initial diagnostics in neutropenic sepsis to avoid fluid overload. Leukemia and neutropenia necessitate rapid pathogen identification for targeted treatment.
Question 5
A 72-year-old with COPD and heart failure (LVEF 30%) develops acute hypoxemia (SpO2 88% on 2L NC) 48 hours post-hip replacement. The nurse reviews the care plan while noting a recent 5-lb weight gain and new crackles bilaterally. Which outcome indicator should be prioritized for real-time monitoring to prevent escalation?
- A) A) Hourly urine output measurement
- B) B) Daily Braden Scale reassessment
- C) C) Respiratory rate trend every 4 hours✓
- D) D) Pain score documentation during mobility
Show rationale
Respiratory rate is an early sepsis indicator per CMS core measures and detects acute decompensation in cardiopulmonary patients. Option C aligns with hypoxemia, weight gain (suggestive of heart failure exacerbation), and crackles. Option A doesn't address respiratory cues. Option B focuses on skin integrity, irrelevant to acute respiratory change. Option D addresses comfort but not the imminent respiratory risk. Early respiratory monitoring supports National Patient Safety Goals for deterioration recognition.
Question 6
A night-shift nurse identifies an undocumented DNR order discrepancy for a terminal cancer patient with declining status. The covering resident states, "Handle it dayshift." Family members express conflicting resuscitation preferences. Which step adheres to chain of command protocols?
- A) A) Clarify code status with family using hospital consent forms
- B) B) Page the attending physician for immediate order verification
- C) C) Inform the house supervisor to resolve documentation and communication issues✓
- D) D) Follow the most recent written order until dayshift arrival
Show rationale
Engaging the house supervisor (C) appropriately addresses multi-level failures: missing documentation, resident dismissal, and family conflicts. Option A exceeds nursing scope in code status determination. Option B bypasses supervisory channels despite non-urgent patient status. Option D ignores ethical risks from contradictory information. The terminal diagnosis and conflicting cues require supervisory intervention per AMSN end-of-life communication protocols.
Question 7
While assisting with a laparoscopic cholecystectomy, the circulating nurse observes the surgeon's sterile glove make contact with the non-sterile anesthesia screen while reaching for an instrument. The patient has type 2 diabetes and a BMI of 38. What is the nurse's most appropriate action?
- A) A) Request the surgeon immediately reglove without breaking scrub and replace the contaminated instrument
- B) B) Document the event in the chart but allow the procedure to continue uninterrupted
- C) C) Notify the surgeon of the contamination and request replacement of both glove and instrument✓
- D) D) Apply sterile iodine solution to the glove and instrument to maintain field sterility
Show rationale
Contact with non-sterile surfaces breaches surgical asepsis per AORN guidelines. Both glove and instrument are contaminated and must be replaced to prevent surgical site infection, especially with the patient's diabetes and obesity increasing infection risk. Option A is incorrect because regloving alone doesn't address instrument contamination. Option B neglects immediate intervention for a sterility breach. Option D violates principles as disinfectants can't salvage contaminated items.
Question 8
During repositioning, a nurse notes a deep tissue injury (suspected) with purple marbling on a patient’s hip. The patient has sepsis and requires vasopressors. What action aligns with current guidelines?
- A) A) Document as Stage 3 pressure injury and initiate wet-to-dry dressings
- B) B) Stage the injury as Unstageable and debride necrotic tissue immediately
- C) C) Record as suspected deep tissue injury and avoid pressure on the area✓
- D) D) Classify as a medical device-related injury and remove all linens
Show rationale
Purple marbling indicates suspected deep tissue injury (SDTI), per NPIAP. Pressure avoidance prevents progression to full-thickness injury. Staging as Stage 3 (A) or Unstageable (B) is incorrect before tissue breakdown occurs. Debridement is contraindicated for SDTI. Device-related injuries (D) involve equipment contact, not bony prominences. Vasopressors exacerbate tissue ischemia, necessitating urgent offloading.
Question 9
A diabetic patient with a 3-month-old implanted port develops fever (38.8°C/102°F) and erythema over the port site 12 hours after infusion. Blood cultures from the port lumen grow Staphylococcus aureus. Which intervention reflects priority management per CDC guidelines?
- A) A) Administer IV vancomycin via peripheral line while awaiting sensitivity results
- B) B) Remove the infected port immediately and initiate culture-directed antibiotics✓
- C) C) Flush the port with antibiotic lock therapy and continue systemic antibiotics
- D) D) Obtain additional blood cultures from peripheral veins before starting treatment
Show rationale
Port-site infection with systemic signs and positive cultures confirms port-associated bloodstream infection. CDC guidelines mandate removal of the infected device plus antibiotics. Option A delays source control. Option C is contraindicated for tunnel/port-site infections. Option D is incorrect because bacteremia is already confirmed; delaying treatment risks sepsis. Removal eliminates the biofilm reservoir, which is critical in device-related S. aureus infections.
Question 10
While assisting with a sterile dressing change for a burn patient, a nurse's sterile glove tears after contact with bed rails. The patient has neutropenia and Pseudomonas aeruginosa in recent cultures. Which action maintains aseptic technique?
- A) A) Complete the procedure using the torn glove after applying alcohol gel
- B) B) Remove gloves, perform a 90-second hand wash, and reglove✓
- C) C) Cover the tear with sterile tape and continue the dressing change
- D) D) Replace the torn glove immediately without re-scrubbing hands
Show rationale
Neutropenia and Pseudomonas risk necessitate rigorous asepsis. Hand washing removes contaminants from bed rail contact; 90 seconds meets WHO standards for high-risk situations. Option A compromises sterility: alcohol gel doesn't remove organic debris. Option C violates principles: tape isn't sterile and seals contaminants. Option D is insufficient: glove replacement alone doesn't address hand contamination. AORN guidelines mandate rescrubbing after glove integrity loss in immunocompromised patients.
Question 11
A unit using team nursing cares for four patients: 1) Post-op hip replacement with dementia, 2) CHF with telemetry, 3) Sepsis on IV antibiotics, and 4) COPD needing discharge teaching. The LPN reports the sepsis patient's rising temperature. Which RN action demonstrates effective model application?
- A) A) Delegate sepsis assessment to an experienced CNA while teaching the COPD patient
- B) B) Assess the sepsis patient immediately and direct the LPN to monitor others✓
- C) C) Complete COPD discharge teaching before checking the sepsis patient
- D) D) Request the charge nurse reassign the sepsis patient to another team
Show rationale
Team nursing uses RNs for complex assessments while delegating stable patients. Sepsis (acute instability cue) requires RN assessment per clinical urgency. Option B prioritizes this while utilizing the LPN for monitoring. Option A inappropriately delegates an unstable patient. Option C delays urgent assessment. Option D disrupts team continuity. The model balances delegation with RN responsibility for critical changes.
Question 12
In post-operative care for a 65-year-old with COPD undergoing abdominal surgery, which ventilator bundle component takes priority when the patient's SpO₂ drops to 88% on day 2 of mechanical ventilation?
- A) A) Elevating the head of the bed to 30-45 degrees immediately✓
- B) B) Administering prescribed bronchodilators via the ventilator circuit
- C) C) Performing a spontaneous breathing trial after suctioning secretions
- D) D) Assessing endotracheal tube cuff pressure with a manometer
Show rationale
A is correct: IHI VAP bundles prioritize head elevation to improve oxygenation and reduce aspiration risk during acute desaturation. B is incorrect: Bronchodilators address bronchospasm but don't correct positioning-related hypoxemia. C is incorrect: Breathing trials require stability; hypoxia contraindicates this step. D is incorrect: Cuff checks prevent microaspiration but aren't urgent for desaturation. The COPD history increases VAP vulnerability, making positioning critical.
Question 13
A patient with stage 3 sacral pressure injury has copious yellow drainage and foul odor. Which assessment finding warrants immediate intervention?
- A) A) Periwound erythema extending 4 cm from the wound edge✓
- B) B) Pain score of 6/10 during dressing changes
- C) C) Undermining of 1 cm at the wound’s superior margin
- D) D) Eschar formation in the wound’s central region
Show rationale
Erythema >2 cm suggests advancing cellulitis or systemic infection, requiring antibiotics. Pain (B) and undermining (C) need management but aren’t urgent without infection signs. Eschar (D) requires monitoring but isn’t acute. Copious drainage/odor indicate infection; NPIAP links extensive erythema to sepsis risk. Prompt intervention prevents osteomyelitis.
Question 14
A Buddhist patient with metastatic cancer requests "no CPR" in his living will but worries refusing resuscitation violates his faith's teachings on preserving life. The nurse's best response addresses which ethical principle?
- A) A) Beneficence by emphasizing comfort-focused care
- B) B) Autonomy by supporting his right to choose✓
- C) C) Nonmaleficence by avoiding painful interventions
- D) D) Justice by ensuring equal access to directives
Show rationale
Advance directives center on self-determination, so option B validates the patient's authority to reconcile personal beliefs with medical choices. Option A shifts focus to clinician priorities. Option C addresses harm reduction but not his moral conflict. Option D discusses systemic issues, not individual concerns. Nurses must affirm autonomy in faith-based dilemmas per AMSN's ethics guidelines, facilitating decisions aligned with personal values.
Question 15
An 82-year-old with diabetes insipidus is admitted with sepsis. Over 8 hours, urine output increases to 400 mL/hr via Foley catheter, and serum sodium rises from 142 to 158 mEq/L. The patient is lethargic but hemodynamically stable. Which action is critical?
- A) A) Administer intravenous D5W at 200 mL/hour
- B) B) Give subcutaneous desmopressin 2 mcg immediately
- C) C) Replace urine output with 0.45% saline mL/mL hourly✓
- D) D) Initiate oral rehydration with electrolyte solution
Show rationale
This hypernatremia stems from diabetes insipidus exacerbated by sepsis. Replacing losses with hypotonic fluid (C) matches urine composition and prevents rapid sodium shifts. D5W (A) causes osmotic fluid shifts risking cerebral edema. Desmopressin (B) is indicated for central DI but unsafe in sepsis-induced DI without confirming etiology. Oral rehydration (D) is insufficient for this urine volume and lethargy. Cues (rapid sodium rise, massive diuresis, altered mentation) require precise IV replacement per ASPEN guidelines.
