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 A
Explanation
Premature ventricular contractions (PVCs) are abnormal heart rhythms originating from the ventricles. They can be triggered by various factors, including irritation or stimulation of the airway during suctioning.
In this situation, the priority is to ensure adequate oxygenation and ventilation for the patient. Stopping the suctioning procedure and providing ventilatory support with 100% oxygen helps maintain oxygen levels and minimizes further cardiac dysrhythmias.
B. Check the patient's potassium level in (option B) is incorrect because While electrolyte imbalances, including low potassium levels (hypokalemia), can contribute to cardiac dysrhythmias, checking the potassium level is not the immediate priority when PVCs occur during suctioning.
C. Give prescribed PRN antidysrhythmic medications in (option C) is incorrect because: Administering antidysrhythmic medications without further assessment or evaluation may not be appropriate in this situation.
D. Decrease the suction pressure to 80 mm Hg in (option D) is incorrect because: While adjusting suction pressure may help prevent further irritation, it is not the initial priority when PVCs are present during suctioning.
E. Documenting the dysrhythmia in the patient's chart in (option E) is incorrect because: Documentation is important but should not be the initial action when a patient experiences PVCs during suctioning. Patient safety and immediate intervention take precedence.
Therefore, when PVCs occur during suctioning, the nurse should stop the procedure, provide ventilatory support with 100% oxygen, and assess the patient's response to intervention.
Correct Answer is C
Explanation
In septic shock, one of the key goals of management is to restore and maintain adequate intravascular volume. However, in this case, the patient's urine output is low (30 mL/hr for the past 3 hours), suggesting inadequate renal perfusion and potential fluid overload.
Administering additional normal saline at an increased rate (250 mL/hr) without addressing the low urine output could potentially exacerbate fluid overload and further compromise the patient's condition.
A. Administer hydrocortisone (Solu-Cortef) 100 mg IV in (option A) is incorrect because: Hydrocortisone is commonly used in septic shock to help stabilize blood pressure and modulate the inflammatory response.
B. Giving PRN furosemide (Lasix) 40 mg IV in (option B) is incorrect because Furosemide, a loop diuretic, can be administered as needed to address fluid overload or to increase urine output if there is evidence of volume overload.
D. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg in (option D) is incorrect because: Norepinephrine is a vasopressor commonly used in septic shock to increase systemic vascular resistance and maintain adequate blood pressure.
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