A 20-year-old female is being admitted to the hospital with fever and septic shock. Which set of assessment findings would the nurse expect the patient to exhibit?

Bradycardia, palpitations, confusion, truncal rash.

Severe respiratory distress, jugular venous distention, chest pain.

Low blood pressure and tachycardia.

Reduced cardiac output, increased systemic vascular resistance, moist cough.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Bradycardia, palpitations, confusion, and truncal rash are not typically associated with septic shock. Septic shock is a severe infection that occurs when bacteria enter the bloodstream. It can cause organs to fail and can lead to death.
Choice B rationale
Severe respiratory distress, jugular venous distention, and chest pain are more commonly associated with conditions like heart failure or pulmonary embolism, not septic shock.
Choice C rationale
Low blood pressure and tachycardia are common symptoms of septic shock. This happens because the body’s response to the infection causes blood vessels to dilate, which can lower blood pressure. The heart rate often increases (tachycardia) in an attempt to maintain blood flow to the organs.
Choice D rationale
Reduced cardiac output, increased systemic vascular resistance, and a moist cough are not typical symptoms of septic shock. These symptoms are more commonly associated with conditions like heart failure.

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Correct Answer is D

Explanation

The symptoms described - tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum - are indicative of acute pulmonary edema, a condition characterized by fluid accumulation in the lungs due to heart failure. In this situation, the Fowler’s position (sitting up at a 45-60 degree angle) with legs lowered is recommended. This position helps to reduce venous return to the heart, thereby decreasing the workload on the heart and helping to alleviate symptoms.

A. On the left side at the midclavicular line, fifth intercostal space. B. Directly over the heart on the sternum. C. On the right side at the midclavicular line, fourth intercostal space. D. At the midaxillary level on the left side.

Correct Answer is A

Explanation

Choice A rationale
The apical pulse, also known as the point of maximal impulse (PMI), is located at the fifth intercostal space at the left midclavicular line. This is the location where the heartbeat is strongest and is the standard location for assessing the apical heart rate.
Choice B rationale
Placing the stethoscope directly over the heart on the sternum is not the standard method for assessing the apical heart rate. While the sternum is close to the heart, it is not the location where the heartbeat is strongest or most easily heard.
Choice C rationale
The right side at the midclavicular line, fourth intercostal space, is not the standard location for assessing the apical heart rate. The heart is located more towards the left side of the chest, and the apical pulse is typically not as easily heard on the right side.
Choice D rationale
The midaxillary line on the left side is not the standard location for assessing the apical heart rate. While this location is on the left side of the chest, it is not where the heartbeat is strongest or most easily heard.

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A 20-year-old female is being admitted to the hospital with fever and septic shock. Which set of assessment findings would the nurse expect the patient to exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client exhibits tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum. What position should the nurse place the client in?

Correct Answer is D

Explanation

In the context of interprofessional care of the client and family, where should a nurse position the stethoscope on the chest to assess a client’s apical heart rate?

Correct Answer is A

Explanation

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