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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. 

A.

Insert a nasogastric (NG) tube.

B.

Measure lactate level.

C.

Obtain a wound culture.

D.

Administer broad-spectrum antibiotics.

E.

Obtain blood cultures.

F.

Type and cross-match for 2 units of packed RBCs.

G.

Rapidly administer 30 mL/kg of normal saline.

H.

Obtain a urine specimen.

Answer and Explanation

Correct Answer : B,D,E,G

A.    Inserting a nasogastric (NG) tube is not a priority action in the initial management of sepsis. 
B.    Measuring lactate levels is a priority action in the initial management of sepsis. Elevated lactate levels indicate tissue hypoxia and are associated with increased mortality in septic patients. 
C.    Obtaining a wound culture is not a priority action in the initial management of sepsis. 
D.    Administering broad-spectrum antibiotics is a priority action in the initial management of sepsis. Prompt antibiotic therapy is associated with improved outcomes in septic patients. 
E.    Obtaining blood cultures is a priority action in the initial management of sepsis. Blood cultures help identify the causative organism and guide antibiotic therapy. 
F.    Type and cross-matching for packed RBCs is not a priority action in the initial management of sepsis. 
G.    Rapidly administering 30 mL/kg of normal saline is a priority action in the initial management of sepsis. This bolus of fluid helps restore tissue perfusion and hemodynamic stability. 
H.    Obtaining a urine specimen is not a priority action in the initial management of sepsis. 
 


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Related Questions

Correct Answer is A

Explanation

A. Albumin is a protein that is produced by the liver and is a good indicator of nutritional status. TPN is intended to provide adequate nutrition to the patient, so an increase in albumin levels would indicate that the treatment is effective.
B. Calcium levels are not directly related to the effectiveness of TPN. Calcium levels can be affected by a variety of factors and are not a specific marker for the effectiveness of TPN.
C. Hematocrit (Hct) measures the percentage of red blood cells in the blood. It is not directly related to the effectiveness of TPN.
D. White blood cell count (WBC) is a marker of immune function and is not directly related to the effectiveness of TPN.

Correct Answer is C

Explanation

        1. The foot is not a typical site for obtaining a blood specimen by venipuncture.
        2. This arm is not ideal for venipuncture because the client is receiving IV fluids through an IV catheter in the basilic vein of the right forearm.
        3. The left forearm is a suitable site for venipuncture because the client is receiving IV fluids through an IV catheter in the basilic vein of the right forearm.
        4. The right forearm is not ideal for venipuncture because the client is receiving IV fluids through an IV catheter in the basilic vein of the right forearm.

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