A 29-year-old female patient is admitted to the emergency department with two of the systemic inflammatory response syndrome variables: temperature of 101.2 °F and 14,000 per μL white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate?
Cooling baths
Broad-spectrum antibiotics
Blood transfusion
NPO status
The Correct Answer is B
The patient's symptoms of fever and elevated white blood cell count suggest a potential infection and sepsis. Broad-spectrum antibiotics should be initiated promptly to cover a wide range of possible pathogens until further diagnostic tests and identification of the specific causative agent are obtained. Early administration of appropriate antibiotics is crucial in sepsis management to target the suspected infection and improve patient outcomes.
A. Cooling baths in (option A) is incorrect because: Cooling baths are typically used in the management of hyperthermia or specific conditions like heatstroke. While the patient has an elevated temperature, it is likely due to the systemic inflammatory response rather than solely hyperthermia.
C. Blood transfusion in (option C) is incorrect because Blood transfusion may be required in certain cases of sepsis if there is evidence of significant anemia or active bleeding. However, based on the information provided, there is no immediate indication of a blood transfusion.
D. NPO status in (option D) is incorrect because NPO status (nothing by mouth) is a general precautionary measure used in various situations, such as prior to surgery or to manage gastrointestinal complications. It is not a specific intervention in the sepsis resuscitation bundle.
Therefore, the nurse should initiate the intervention of administering broad-spectrum antibiotics in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In the initial 24 hours after burn injury, fluid resuscitation is a critical priority in the management of burn patients. Burn injuries can lead to significant fluid loss, both locally at the burn site and systemically due to increased capillary permeability. Fluid resuscitation aims to restore and maintain adequate intravascular volume, ensuring sufficient tissue perfusion and organ function.
The Parkland Formula is commonly used to guide fluid resuscitation in burn patients. It involves calculating the total volume of fluid needed in the first 24 hours, with a portion given in the initial hours after injury and the remainder given over the remaining hours.
A. Sterile dressing changes (option A) are incorrect because they are important in wound care management for burn patients to prevent infection. However, fluid resuscitation takes precedence within the first 24 hours.
B. Emotional support (option B) is incorrect because it is an essential aspect of burn care, as burn injuries can have a significant psychological impact. While emotional support is crucial for the patient's overall well-being, it may not be the highest priority within the first 24 hours compared to addressing the physiological needs of fluid resuscitation.
D. Range-of-motion exercises (option D) are incorrect because they are important for preventing contractures and maintaining joint mobility in burn patients. However, they are typically initiated after the initial fluid resuscitation phase and wound stabilization.
Therefore, the priority the nurse anticipates within the first 24 hours for a 31-year-old male patient with burn injuries is fluid resuscitation.
Correct Answer is ["21"]
Explanation
flow rate for an infusion= (Volume in mL * Drop factor) / Time in minutes.
volume of the infusion bag is 250 mL, the drop factor is 10 gtts/mL, and the time is 2 hours, which is 120 minutes.
(250 mL * 10 gtts/mL) / 120 minutes = 2500 gtts / 120 minutes ≈ 20.83 gtts/minute. Therefore, the nurse should run the infusion at a rate of approximately 21 drops per minute to deliver 1 unit of packed red blood cells over the 2-hour period.
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