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 B

Explanation

Choice A rationale:

While promptly removing urinary catheters can reduce the risk of catheter-associated urinary tract infections (CAUTIs), it addresses only one specific type of infection. It doesn't comprehensively address other common healthcare-associated infections (HAIs) like central line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections (CDI).

Education about infection control methods, however, encompasses a broader range of preventive measures that can be applied to various HAIs, making it a more effective strategy for overall infection prevention.

Choice C rationale:

Placing patients in appropriate isolation can prevent the spread of infections, but it's a reactive measure that's implemented after an infection has already occurred. It doesn't address the root causes of infections or prevent their occurrence in the first place.

Education about infection control methods, on the other hand, is a proactive approach that aims to prevent infections from happening in the first place by teaching staff about proper hygiene practices, aseptic techniques, and other infection prevention strategies.

Choice D rationale:

Monitoring hand hygiene practices is crucial for infection prevention, but it's only one aspect of a comprehensive infection control program. Education about infection control methods goes beyond hand hygiene and covers various other preventive measures, such as:

Proper use of personal protective equipment (PPE) Aseptic technique during invasive procedures

Proper cleaning and disinfection of equipment and surfaces Proper handling of patient waste

Recognition of signs and symptoms of infection Prompt reporting of potential outbreaks

Therefore, educating staff members about infection control methods is the most effective action the nursing manager can take to prevent infections in the hospital unit because it provides a comprehensive approach to infection prevention, addressing various aspects of HAI prevention and promoting a culture of safety among healthcare staff.

A. Notify the primary health care provider and request antibiotics. B. Inform the client that this signifies inflammation. C. Document findings and continue monitoring. D. Place the client in protective isolation.

Correct Answer is A

Explanation

Rationale for Choice A:
A shift to the left in the white blood cell (WBC) count indicates an increased presence of immature neutrophils, known as bands. This is a hallmark sign of infection, as the body is rapidly producing and releasing these cells to fight off invading pathogens.
Prompt notification of the primary health care provider is crucial to initiate timely antibiotic therapy, if indicated. Early intervention with appropriate antibiotics can effectively combat the infection, prevent its progression, and potentially avert serious complications.
Delaying antibiotic treatment can allow the infection to worsen, potentially leading to sepsis, septic shock, or other life- threatening conditions.
Rationale for Choice B:
While informing the client about the significance of a shift to the left is important for education and understanding, it does not address the immediate need for medical intervention.
The priority action is to involve the primary health care provider for prompt assessment and potential initiation of antibiotic therapy.
Rationale for Choice C:
Documenting findings and continuing to monitor the client's condition is essential for ongoing assessment and evaluation, but it does not constitute a proactive intervention to address the underlying infection.
Documentation alone does not initiate treatment, and monitoring without intervention risks allowing the infection to progress.
Rationale for Choice D:
Protective isolation is not routinely indicated for clients with a shift to the left in their WBC count unless there is a specific concern for transmission of a highly contagious infection.
The decision to implement protective isolation measures would be based on the client's overall clinical presentation and potential infectious risks, as determined by the primary health care provider.

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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

A nursing manager is worried about the number of infections in the hospital unit. What action by the manager would be most effective in preventing these infections?

Correct Answer is B

Explanation

Choice A rationale:

Choice C rationale:

Choice D rationale:

A nurse receives a report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?

Correct Answer is A

Explanation

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