A 48-year-old female patient with septic shock presents with a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose of 246 mg/dl. The following have been ordered. Which order will the nurse accomplish first?

Draw an arterial blood gas (ABG).

Start insulin drip to maintain blood glucose at 150 mg/dl or lower.

Give a normal saline bolus IV of 30mL/kg.

Titrate norepinephrine (Levophed) to keep MAP greater than 65 mm Hg.

Answer and Explanation

The Correct Answer is C

Septic shock is characterized by inadequate tissue perfusion and hypotension, which can lead to organ dysfunction and failure. The administration of intravenous fluids, such as a normal saline bolus, is the initial priority in the management of septic shock to restore intravascular volume and improve perfusion.
A. Draw an arterial blood gas (ABG) in (option A) is incorrect because: ABG may be ordered to assess the patient's acid-base status and oxygenation, but addressing hypotension and restoring perfusion through fluid administration takes priority.
B. Start insulin drip to maintain blood glucose at 150 mg/dl or lower in (option B) is incorrect because: Hyperglycaemia is commonly observed in critically ill patients, including those with septic shock. While controlling blood glucose is important, it is not the immediate priority compared to addressing hypotension and restoring intravascular volume.
D. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) greater than 65 mm Hg in (option D) is incorrect because: Norepinephrine is a vasopressor medication used to increase blood pressure and perfusion in septic shock. While it may be necessary for the management of septic shock, fluid resuscitation should be initiated first to optimize intravascular volume before starting vasopressors.
Therefore, the first order that the nurse should accomplish in this scenario is to give a normal saline bolus IV of 30 mL/kg to address the hypotension and restore intravascular volume.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. obtaining wound and blood B. removing or controlling potentially infected sources C. initiation of an intravenous line and fluid D. drawing blood for hematology and chemistry studies

Correct Answer is C

Explanation

Septic shock is a life-threatening condition characterized by severe infection, systemic inflammation, and inadequate tissue perfusion. In this critical situation, one of the initial priorities is to restore intravascular volume and improve tissue perfusion. Initiation of an intravenous line allows for the administration of fluids and other necessary medications to support the patient's hemodynamic stability.
While the other interventions mentioned are also important components of septic shock management, the immediate priority is to address hypotension and tissue hypoperfusion through fluid resuscitation:
A. Obtaining wound and blood cultures in (option A) is incorrect because: Cultures are important to identify the source and causative organisms of the infection. However, fluid resuscitation should take priority over obtaining cultures, as it is necessary to stabilize the patient's hemodynamics.
B. Removing or controlling potentially infected sources in (option B) is incorrect because: Identifying and controlling the source of infection is crucial in septic shock management to prevent further progression. However, initiating fluid resuscitation is more time-sensitive and should be prioritized.
D. Drawing blood for hematology and chemistry studies in (option D) is incorrect because Laboratory studies are important for evaluating organ function and guiding treatment. However, the immediate focus should be on fluid resuscitation to address the underlying hypoperfusion and stabilize the patient's condition.
Therefore, the intervention considered a priority when treating a patient who presents with septic shock is the initiation of an intravenous line and fluid administration to restore intravascular volume and improve tissue perfusion.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A 48-year-old female patient with septic shock presents with a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose of 246 mg/dl. The following have been ordered. Which order will the nurse accomplish first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 31-year-old male patient with burn injuries is admitted to the burn unit. Which priority does the nurse anticipate within the first 24 hours?

Correct Answer is C

Explanation

Which of the following interventions is considered a priority when treating a patient who presents with septic shock?

Correct Answer is C

Explanation

Which of the following findings is most consistent with disseminated intravascular coagulation (DIC)?

Patients in shock receive fresh frozen plasma to replace which one of the following?

The emergency department nurse is assessing a patient who is in the compensatory stage of hypovolemic shock. Which manifestations does the nurse expect? Select all that apply.

Which conditions can cause hypovolemic shock? Select all that apply.

A student is caring for a patient who suffered massive blood loss after trauma. How does the student correlate the blood loss with the patient's mean arterial pressure (MAP)?

A 66-year-old female patient in septic shock has received fluid resuscitation, but their mean arterial pressure (MAP) is 52 mmHg. The nurse anticipates the administration of which one of the following?