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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.

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.

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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.

A. Atorvastatin B. Metformin C. Carvedilol D. Nitroglycerin

Correct Answer is B

Explanation

B Metformin is an oral antidiabetic medication commonly used to treat type 2 diabetes. There is a potential risk of lactic acidosis when metformin is used in conjunction with contrast material, particularly in patients with underlying renal impairment. Contrast-induced nephropathy can exacerbate renal dysfunction, leading to increased levels of metformin and potentially increasing the risk of lactic acidosis. Therefore, metformin use before or after contrast administration should be carefully monitored, and in some cases, temporarily discontinued to reduce the risk of lactic acidosis.

A Atorvastatin is a statin medication commonly used to lower cholesterol levels. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast-induced nephropathy (CIN).

C Carvedilol is a beta-blocker medication used to treat high blood pressure and heart failure. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast-induced nephropathy (CIN).

D Nitroglycerin is a medication commonly used to relieve chest pain (angina) in patients with coronary artery disease. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast- induced nephropathy (CIN).

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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

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

Explanation

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Correct Answer is B

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?