A nurse is caring for a 73-year-old client in the emergency department (ED).
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.
Insert a nasogastric (NG) tube.
Measure lactate level.
Obtain a wound culture.
Administer broad-spectrum antibiotics.
Obtain blood cultures.
Type and cross-match for 2 units of packed RBCs.
Rapidly administer 30 mL/kg of normal saline.
Obtain a urine specimen.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To calculate the number of tablets the nurse should dispense to the client, we need to convert the prescribed dose of digoxin from milligrams (mg) to micrograms (mcg), as the tablets are labeled in milligrams.
1 mg = 1000 mcg
125 mcg = (125 mcg) / (1000 mcg/mg) = 0.125 mg
Now, we can determine the number of tablets needed to achieve this dose:
0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets
Correct Answer is C
Explanation
A. This statement suggests a delusion or hallucination, which are common symptoms of some mental disorders, but it does not specifically suggest an inability to process new information.
B. This statement suggests paranoia, which is a common symptom of some mental disorders, but it does not specifically suggest an inability to process new information.
C. This statement suggests difficulty with memory, which is a cognitive function that is related to the ability to process new information.
D. This statement suggests a persistent negative mood, which is a symptom of some mental disorders, but it does not specifically suggest an inability to process new information.
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