A nurse in a provider’s office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition?

Choice A: Type and match for 2 units of packed RBCs

This option is not typically part of the initial management of sepsis. Typing and matching for blood transfusion is generally reserved for patients who are experiencing significant blood loss or severe anemia. In this case, the patient’s hemoglobin and hematocrit levels are within normal ranges, indicating that a blood transfusion is not immediately necessary. The primary focus in the first hour of sepsis management is to stabilize the patient through fluid resuscitation, infection control, and monitoring vital signs.

Choice B: Rapidly administer 30 mL/kg of normal saline

Rapid fluid resuscitation is a critical component of sepsis management. Administering 30 mL/kg of normal saline helps to restore intravascular volume, improve tissue perfusion, and prevent organ failure. This intervention is particularly important in patients with hypotension or elevated lactate levels, as it helps to maintain adequate blood pressure and oxygen delivery to tissues. The Surviving Sepsis Campaign guidelines recommend this approach to stabilize patients and prevent further complications.

Choice C: Measure lactate level

Measuring lactate levels is essential in the early management of sepsis. Elevated lactate levels indicate tissue hypoperfusion and anaerobic metabolism, which are hallmarks of sepsis and septic shock. Monitoring lactate levels helps to assess the severity of the condition and guide further treatment decisions. The Surviving Sepsis Campaign guidelines emphasize the importance of measuring lactate levels within the first hour of sepsis recognition. If the initial lactate level is elevated, it should be remeasured to evaluate the effectiveness of the interventions.

Choice D: Obtain blood cultures

Obtaining blood cultures before administering antibiotics is crucial for identifying the causative pathogen and tailoring antibiotic therapy. Blood cultures help to determine the source of infection and guide appropriate antimicrobial treatment. Early identification and targeted therapy are essential for improving patient outcomes in sepsis. The Surviving Sepsis Campaign guidelines recommend obtaining blood cultures as part of the initial management of sepsis.

Choice E: Obtain a wound culture

Obtaining a wound culture is important in this case because the patient has a wound with purulent drainage, which could be a potential source of infection. Identifying the specific pathogen responsible for the wound infection allows for targeted antibiotic therapy, which is more effective than broad-spectrum antibiotics. This intervention helps to control the source of infection and prevent further complications. The Surviving Sepsis Campaign guidelines support source control measures, including obtaining wound cultures, as part of the initial management of sepsis.

Choice A reason:

A client with a tracheostomy tube attached to humidified oxygen is not typically at risk for hypokalemia. The primary concerns for these clients are maintaining a patent airway, preventing infection, and ensuring adequate humidification to prevent mucus plugging.

Choice B reason:

A client with an indwelling urinary catheter to gravity drainage is not specifically at risk for hypokalemia. The main risks for these clients include urinary tract infections and ensuring proper catheter care to prevent blockages.

Choice C reason:

A client with a chest tube to water seal is primarily at risk for complications related to the chest tube itself, such as infection, pneumothorax, or improper drainage. Hypokalemia is not a common risk associated with chest tubes.

Choice D reason:

A client with a nasogastric tube to suction is at risk for hypokalemia. Continuous suctioning can lead to the loss of gastric contents, which contain potassium, leading to a decrease in potassium levels in the body. This can result in hypokalemia, which needs to be monitored and managed appropriately.