A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?

Encourage oral intake of water

Administer potassium-sparing diuretic

Restrict fluid intake

Administer IV bolus of normal saline

Answer and Explanation

The Correct Answer is D

A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.

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Correct Answer is ["D","E","F","G"]

Explanation

D. Measure lactate level: Elevated lactate levels are a strong indicator of sepsis and can help guide treatment.

E. Administer broad-spectrum antibiotics: Prompt administration of antibiotics is crucial to combat the infection.

F. Rapidly administer 30 mL/kg of normal saline: Aggressive fluid resuscitation is necessary to improve blood pressure and tissue perfusion.

G. Obtain blood cultures: Blood cultures can help identify the specific organism causing the infection and guide antibiotic therapy.

Other interventions that may be considered, but not necessarily within the first hour, include:

A. Obtain a urine specimen: This can help identify a urinary tract infection as a potential source of sepsis.

B. Insert a nasogastric tube: This may be necessary if the client is unable to tolerate oral intake or requires gastric decompression.

C. Type and cross-match for 2 units of packed RBCs: This may be necessary if the client develops significant anemia or requires blood transfusion.

A. Blood pressure increases. B. Blood vessels become more permeable. C. Blood vessels constrict. D. White blood cells are destroyed.

Correct Answer is B

Explanation

A. Blood pressure does not increase during anaphylaxis; instead, it typically decreases due to vasodilation and fluid leakage.
B. During anaphylaxis, blood vessels become more permeable, leading to the release of fluids into the tissues, which causes swelling and contributes to hypotension.
C. Blood vessels do not constrict during anaphylaxis; rather, they dilate as a part of the allergic response, resulting in decreased blood pressure.
D. While there is an immune response during anaphylaxis, white blood cells are not destroyed; rather, they are activated to respond to the allergen, leading to inflammation and other systemic effects.

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A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 73-year-old client in the emergency department (ED) Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

Correct Answer is ["D","E","F","G"]

Explanation

A nurse is caring for a client who has a peanut allergy. The client ate peanut butter and is now experiencing anaphylaxis. Which of the following physiological responses should the nurse expect to occur?

Correct Answer is B

Explanation

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A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?

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