A client is admitted with possible sepsis. Which action will the nurse perform first?

Administer an antipyretic.

Obtain specified cultures.

Administer antibiotics.

Place the client in isolation.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Administering an antipyretic would lower the client's fever, but it would not address the underlying cause of the sepsis. Antipyretics can mask important signs and symptoms of infection, making it more difficult to diagnose and treat the sepsis. It's important to identify the causative organism of sepsis to initiate appropriate antibiotic therapy.
Therefore, obtaining cultures to identify the causative organism is the priority action.
Choice B rationale:
Obtaining specified cultures is the most important action for a client with possible sepsis because it allows for the identification of the causative organism.
This information is essential for selecting the appropriate antibiotic therapy. Cultures should be obtained as soon as possible, before antibiotics are administered.
Choice C rationale:
While administering antibiotics is an important part of the treatment for sepsis, it is not the first action that the nurse should take.
Antibiotics should be administered after the causative organism has been identified.
Administering antibiotics before cultures are obtained can make it more difficult to identify the causative organism.
Choice D rationale:
Placing the client in isolation is important to prevent the spread of infection, but it is not the first action that the nurse should take.
The priority is to identify the causative organism and initiate appropriate treatment. The client can be placed in isolation after cultures have been obtained.

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Correct Answer is A

Explanation

Choice A rationale:
Leukocyte-poor packed red blood cells (LP-PRBCs) have a significantly reduced number of white blood cells (WBCs), also known as leukocytes. This is crucial for pre-transplant patients like the one in the question for several reasons:
Prevention of Alloimmunization: WBCs in blood transfusions carry human leukocyte antigens (HLAs), which are proteins on the surface of cells that play a role in the immune system. Exposure to foreign HLAs can cause the recipient's immune system to develop antibodies against them, a process called alloimmunization. These antibodies can then attack and damage the transplanted kidney, leading to rejection. By reducing the number of WBCs in the transfusion, LP-PRBCs significantly lower the risk of alloimmunization.
Reduced Incidence of Febrile Non-Hemolytic Transfusion Reactions (FNHTRs): FNHTRs are the most common type of transfusion reaction, characterized by fever, chills, and occasionally other symptoms like nausea and vomiting. They are thought to be caused by cytokines released from WBCs in the transfused blood. LP-PRBCs, with their reduced WBC content, have been shown to lower the incidence of FNHTRs.
Potential Benefits for Graft Survival: Some studies have suggested that the use of LP-PRBCs for transfusions may improve long-term graft survival rates in kidney transplant patients, although more research is needed to confirm these findings.
Choice B rationale:
This statement is incorrect. While LP-PRBCs may have some advantages in terms of absorption or utilization, this is not the primary reason for their use in pre-transplant patients. The main goal is to reduce the risk of alloimmunization and other transfusion-related complications.
Choice C rationale:
This statement is partially correct. LP-PRBCs do tend to cause fewer blood reactions, particularly FNHTRs, as explained in the rationale for Choice A. However, this is not the most comprehensive or accurate explanation for their use in pre-transplant patients.
Choice D rationale:
This statement is not directly relevant to the use of LP-PRBCs in pre-transplant patients. While LP-PRBCs may have a lower risk of hemolysis, this is not the primary reason for their use in this specific context.

A. Metabolic Alkalosis B. Respiratory Alkalosis C. Respiratory Acidosis D. Metabolic Acidosis

Correct Answer is D

Explanation

Choice A rationale:
Metabolic alkalosis is a condition characterized by an increase in the pH of the blood due to an excess of bicarbonate (HCO3-) in the body. It is not typically caused by severe diarrhea. In fact, diarrhea can often lead to a loss of bicarbonate, which can contribute to metabolic acidosis.
Causes of metabolic alkalosis include: excessive vomiting, use of diuretics, and excessive intake of alkali such as antacids. Clinical manifestations of metabolic alkalosis include: muscle twitching, paresthesias, seizures, confusion, and lethargy.
Choice B rationale:
Respiratory alkalosis is a condition characterized by a decrease in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to an increase in blood pH. It is caused by hyperventilation, which removes excess CO2 from the body. Severe diarrhea does not typically cause hyperventilation.
Causes of respiratory alkalosis include: anxiety, hyperventilation syndrome, high altitude sickness, and pulmonary embolism. Clinical manifestations of respiratory alkalosis include: lightheadedness, dizziness, paresthesias, palpitations, and tetany.
Choice C rationale:
Respiratory acidosis is a condition characterized by an increase in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to a decrease in blood pH. It is caused by hypoventilation, which prevents the body from removing enough CO2. Severe diarrhea does not typically cause hypoventilation.
Causes of respiratory acidosis include: chronic obstructive pulmonary disease (COPD), pneumonia, asthma, and neuromuscular disorders.
Clinical manifestations of respiratory acidosis include: headache, confusion, somnolence, and coma.
Choice D rationale:
Metabolic acidosis is a condition characterized by a decrease in the pH of the blood due to an excess of acid in the body or a loss of bicarbonate. Severe diarrhea can lead to metabolic acidosis through several mechanisms:
Loss of bicarbonate in the stool: Diarrhea often contains a significant amount of bicarbonate, which can be lost from the body in large amounts during severe diarrheal episodes. This loss of bicarbonate can lead to a decrease in the blood's pH, resulting in metabolic acidosis.
Dehydration: Severe diarrhea can also lead to dehydration, which can concentrate acids in the blood and contribute to metabolic acidosis.
Lactic acidosis: In some cases, severe diarrhea can also cause lactic acidosis, a type of metabolic acidosis that occurs when there is a buildup of lactic acid in the body. This can happen due to impaired circulation or tissue hypoxia, which can occur as a complication of severe diarrhea.

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A client is admitted with possible sepsis. Which action will the nurse perform first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is providing care for a patient suffering from severe diarrhea. Which acid-base disorder is the patient at risk of developing?

Correct Answer is D

Explanation

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