Try Naxlex NCLEX-RN (Free-Trial)

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.

Type and cross-match for 2 units of packed RBCs.

Administer broad-spectrum antibiotics.

Measure lactate level.

Rapidly administer 30 ml/kg of normal saline.

Obtain blood cultures.

Obtain a urine specimen.

Obtain a wound culture.

Answer and Explanation

Correct Answer : C,D,E,F

A. Administering antibiotics helps target the suspected infection and prevent its spread. Broad-spectrum antibiotics are typically initiated until the specific pathogen is identified through cultures. This action should be completed as soon as possible within the first hour.

D. Lactate measurement is important in assessing tissue perfusion and the severity of sepsis. Elevated lactate levels indicate tissue hypoperfusion and can help identify patients at higher risk of mortality. Monitoring lactate levels guides resuscitation efforts and helps in assessing the response to treatment.

E. Fluid resuscitation is a cornerstone in the management of sepsis. Administering a large volume of intravenous fluids helps restore intravascular volume, improve tissue perfusion, and prevent further organ dysfunction. The recommended initial fluid bolus is 30 ml/kg of crystalloid solution, such as normal saline, administered rapidly within the first few hours of recognition of sepsis.

F. Blood cultures help identify the causative organism(s) responsible for the sepsis. This information is crucial for guiding antibiotic therapy, especially in cases of severe sepsis or septic shock. Blood cultures should be obtained before initiating antibiotic therapy to maximize their sensitivity and specificity.

B. Type and cross-match for packed red blood cells (PRBCs) are indicated in situations where blood transfusion may be required, such as severe anemia or active bleeding. While sepsis can lead to various complications, such as disseminated intravascular coagulation (DIC), the priority in the first hour is resuscitation and antibiotic administration.

G. Obtaining a urine specimen may be indicated to assess for urinary tract infection (UTI), which can be a potential source of sepsis. However, in the initial management of sepsis, obtaining blood cultures (option F) takes precedence as blood cultures provide more critical information for guiding antibiotic therapy.

H. Obtaining a wound culture may help identify the specific pathogens present in the wound and guide antibiotic therapy if the wound is suspected to be the source of sepsis. However, in the first hour of managing sepsis, the priority is to initiate broad-spectrum antibiotics and obtain blood cultures, as these interventions are more urgent in preventing further complications from sepsis.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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

Explanation

B. stroke volume is the amount of blood ejected from the left ventricle with each contraction (systole) of the heart. Changes in stroke volume directly affect cardiac output. An increase in stroke volume leads to an increase in cardiac output, while a decrease in stroke volume results in a decrease in cardiac output. Factors that can affect stroke volume include preload, afterload, and contractility of the heart.

C. Heart rate refers to the number of heartbeats per minute. Heart rate directly affects cardiac output by determining how frequently the heart contracts and pumps blood. An increase in heart rate (tachycardia) leads to an increase in cardiac output, while a decrease in heart rate (bradycardia) results in a decrease in cardiac output. Factors such as sympathetic and parasympathetic nervous system activity, hormones, and medications can influence heart rate.

A. Respiratory rate does not directly affect stroke volume or heart rate but changes in respiratory rate can indirectly impact cardiac output through their effects on venous return and preload.

D. Blood pressure represents the force exerted by the blood against the walls of the arteries. While blood pressure does not directly affect cardiac output, it is influenced by cardiac output and systemic vascular resistance (SVR).

A. Apply restraints if the client becomes agitated. B. Verify the prescribed ventilator settings daily. C. Reposition the endotracheal tube to the opposite side of the mouth daily. D. Administer pantoprazole as prescribed. E. Elevate the head of the bed to at least 30".

Correct Answer is ["B","D","E"]

Explanation

B. This is an essential nursing intervention to ensure that the ventilator is delivering the appropriate settings as ordered by the healthcare provider. Ventilator settings may need to be adjusted based on the client's condition, so daily verification is important for patient safety and optimal ventilator management.

D. Pantoprazole is a proton pump inhibitor commonly used to prevent stress ulcers in critically ill patients receiving mechanical ventilation. It helps reduce gastric acid secretion and can prevent complications such as gastrointestinal bleeding. Administering pantoprazole as prescribed is an appropriate intervention to prevent complications related to stress ulcers in ventilated patients.

E. Elevating the head of the bed to at least 30 degrees is a crucial intervention to prevent ventilator- associated pneumonia (VAP) by reducing the risk of aspiration. This position helps promote drainage of oral and gastric secretions, reducing the likelihood of aspiration into the lungs. It's considered a standard practice in ventilated patients to minimize the risk of pulmonary complications.

A. Apply restraints if the client becomes agitated: While it may be necessary to use restraints in certain situations to ensure the safety of the client and prevent self-extubation or injury, they should be used judiciously and only when other measures to manage agitation have failed. Restraints should not be the first-line intervention and should be used in accordance with facility policies and regulations.

C. Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard nursing intervention. Once the endotracheal tube is properly positioned and secured, it should not routinely need to be repositioned unless clinically indicated due to complications such as mucosal irritation or tube displacement.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Which of the following factors can directly affect cardiac output?

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

Explanation

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted?

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

The nurse is caring for a client with a history of heart failure and notes a new onset of the following rhythm on the client's telemetry monitor. Which action would the nurse take first?

A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate?

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

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?