A 30-year-old female patient is admitted to the emergency department with two systemic inflammatory response syndrome variables: temperature of 100.2°F (35°C) and high blood sugar. Which intervention from the sepsis resuscitation bundle does the nurse initiate?
Cooling baths
Blood transfusion
30 ml/kg of Lactated Ringers (LR)
NPO Status
The Correct Answer is C
The sepsis resuscitation bundle typically includes the administration of intravenous fluids to restore adequate perfusion and address hypovolemia. The initial fluid of choice is often the crystalloid solution, such as Lactated Ringers (LR), and the recommended initial fluid bolus is 30 ml/kg. This intervention aims to optimize intravascular volume and improve tissue perfusion.
A. Cooling baths in (option A) is incorrect because they may be used in the management of hyperthermia or fever, but they are not specific interventions in the sepsis resuscitation bundle.
B. Blood transfusion in (option B) is incorrect it may be necessary in certain cases of sepsis, such as severe anemia or hypovolemia, but it is not a routine intervention in the sepsis resuscitation bundle based solely on the provided information.
D. NPO status (nothing by mouth) in (option D) is incorrect because it is not a specific intervention in the sepsis resuscitation bundle. It may be indicated in certain cases, such as when surgery is required or if there is a risk of aspiration, but it does not directly address the sepsis-related variables mentioned.
It is important to note that the specific management of sepsis may vary based on the patient's individual condition, clinical presentation, and healthcare provider's orders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Oxygen saturation of 92% in (option A) is incorrect because While an oxygen saturation of 92% is suboptimal and may require intervention, it may not have the same immediate implications as low blood pressure. The healthcare provider should be informed, but addressing the blood pressure takes priority.
B. Skin cool and clammy in (option B) is correct because Cool and clammy skin is often associated with inadequate peripheral perfusion, which is a characteristic of septic shock.
C. Septic shock is characterized by systemic inflammation, vasodilation, and hypotension. Inadequate blood pressure is a significant concern in septic shock as it indicates poor tissue perfusion and compromised organ function. However, the mean arterial pressure is till acceptable.
D. Heart rate of 118 beats/minute in (option D) is incorrect because: Tachycardia is a common finding in septic shock and reflects the body's compensatory response to maintain cardiac output. While it is a significant finding, low blood pressure takes precedence in terms of urgency.
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