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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 D

Explanation

A. Clients with bulimia nervosa may have a normal or above-normal body weight, as bulimia nervosa is characterized by episodes of binge eating followed by compensatory behaviors such as vomiting or excessive exercise.
B. Amenorrhea, or the absence of menstruation, is more commonly associated with anorexia nervosa rather than bulimia nervosa.
C. Hyperkalemia, or high levels of potassium in the blood, is not a common finding in clients with bulimia nervosa.
D. Frequent self-induced vomiting can lead to dental erosion and decay due to exposure of the teeth to stomach acid.

A. Secondary B. Quaternary C. Tertiary D. Primary

Correct Answer is C

Explanation

A. Secondary prevention focuses on early detection and intervention to prevent further harm or complications. Tube feeding for a special needs student is not aimed at preventing the initial onset of a condition or injury.
B. Quaternary prevention focuses on avoiding unnecessary medical interventions and reducing the risk of over-medicalization. Tube feeding for a special needs student is a necessary medical intervention.
C. Tertiary prevention focuses on managing and treating existing conditions to prevent further complications or disability. Helping a special needs student with tube feeding is aimed at managing their existing condition (inability to eat orally) to prevent malnutrition or other complications.
D. Primary prevention focuses on preventing the initial onset of a condition or injury. Tube feeding for a special needs student is not aimed at preventing the initial onset of their inability to eat orally.

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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 is caring for a female client who has bulimia nervosa and reports frequent self-induced vomiting. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A school nurse is helping a special needs student with tube feeding during the lunch hour. Which of the following levels of prevention does this fall under?

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.