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
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Correct Answer is B
Explanation
A. While the client may experience depression as a result of their situation, this does not specifically relate to their addiction to internet gaming and gambling.
B. This manifestation is characteristic of non-substance addictions, such as gambling disorder and internet gaming disorder. Despite experiencing negative consequences, the client continues to engage in the addictive behavior
C. This statement may be true, but it does not specifically relate to the client's addiction to internet gaming and gambling.
D. Filing for bankruptcy due to debts and job loss is a consequence of the client's addiction, but it does not specifically relate to their addiction to internet gaming and gambling.
Correct Answer is B
Explanation
A. Using a dosimeter to measure radiation levels may be necessary in certain situations, but it is not the first step in determining what type of PPE to use.
B. Choosing the highest level of protection equipment available is important in minimizing the chances of the provider contacting the disease.
C. Waiting before delivering care might lead to loss of valuable time.
D. Decontaminating victims before intervening is not the nurse's responsibility. The focus should be on protecting oneself and providing care to those who need it.
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