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
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Related Questions
Correct Answer is C,A,D,B,E
Explanation
The correct order is C,A,D,B,E.
C. Open the airway using a jaw-thrust maneuver.
This is the first priority since maintaining a clear airway is critical for the client’s survival.
A. Determine effectiveness of ventilatory efforts.
After ensuring the airway is open, assess the client’s breathing and whether they are ventilating effectively.
D. Perform a Glasgow Coma Scale assessment.
This step evaluates the client’s neurological status to determine their level of consciousness and identify any brain injuries.
B. Remove clothing for a thorough assessment.
To expose the client for a comprehensive physical examination and assess any injuries.
E. Control any external bleeding.
As part of circulation management, identify and stop any significant bleeding to prevent shock. This step addresses the "C" in ABCDE.
Correct Answer is D
Explanation
A. This response dismisses the client's concerns and does not address the underlying issue.
B. This response is appropriate, but it does not address the underlying issue of altered taste perception.
C. This response suggests a solution but does not address the underlying issue of altered taste perception.
D. This response acknowledges the client's concerns and provides an explanation for the altered taste perception, which can be reassuring and informative.
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