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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.

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.

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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Correct Answer is ["A","B","C","E"]

Explanation

A. A weakened gag reflex is a common complication of cervical spinal cord injuries and can lead to difficulty swallowing and increased risk of aspiration.
B. Hyperthermia can occur due to autonomic dysreflexia, a common complication of cervical spinal cord injuries.
C. Absence of bowel sounds can indicate a paralytic ileus, a common complication of cervical spinal cord injuries.
D. Polyuria is not a common complication of cervical spinal cord injuries. It may occur due to other factors, such as diabetes insipidus, but it is not directly related to the injury itself.
E. Hypotension can occur due to autonomic dysreflexia, a common complication of cervical spinal cord injuries.

A. Review the client's medications B. Notify the case manager of the client's wishes for community resources. C. Assist the client with bathing and oral care. D. Assess the client's wound.

Correct Answer is C

Explanation

A. Reviewing the client's medications requires a higher level of education and training than most assistive personnel have.
B. Notifying the case manager of the client's wishes for community resources requires a higher level of education and training than most assistive personnel have.
C. Assisting the client with bathing and oral care is within the scope of practice for most assistive personnel.
D. Assessing the client's wound requires a higher level of education and training than most assistive personnel have.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A home health nurse is working with assistive personnel (AP) to care for a client in their home. Which of the following tasks can the nurse assign to the AP?

Correct Answer is C

Explanation

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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.