A nurse is caring for a 73-year-old client in the emergency department (ED)
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Assessing the client's vital signs, including blood pressure and pulse, provides critical information about the client's hemodynamic status and response to the new rhythm. Atrial fibrillation can lead to rapid, irregular heart rates and hemodynamic instability, so obtaining vital signs promptly helps the nurse determine the severity of the situation and whether immediate intervention is needed.
A. This action is not the priority when the nurse observes a new onset of atrial fibrillation. While beta- blockers such as metoprolol may be part of the client's long-term management for heart failure and atrial fibrillation, initiating medication administration without further assessment could delay appropriate intervention for the acute change in rhythm.
C. While it is important to communicate changes in the client's condition to the healthcare provider, this action should occur after the nurse has assessed the client's vital signs and determined the urgency of the situation. If the client is stable and responsive to initial interventions, the nurse can then contact the healthcare provider to discuss the new onset of atrial fibrillation and collaborate on further management.
D. Documenting the changes in the client's rhythm is important for continuity of care and communication among healthcare team members. However, obtaining a rhythm strip should not be the first action when a new onset of atrial fibrillation is observed. Assessing the client's vital signs and initiating appropriate interventions to address any hemodynamic instability take precedence.
Correct Answer is B
Explanation
B. The QT interval represents ventricular depolarization and repolarization. It starts at the beginning of the QRS complex and ends at the end of the T wave. The QT interval reflects the total time it takes for both ventricular depolarization and repolarization to occur. Prolongation of the QT interval can be associated with an increased risk of arrhythmias, including torsades de pointes.
A. The QRS complex represents ventricular depolarization, which is the electrical activation of the ventricles. The duration of the QRS complex provides information about the time it takes for ventricular depolarization to occur. A prolonged QRS complex can indicate abnormalities in ventricular conduction, such as bundle branch blocks or ventricular hypertrophy.
C. The ST segment represents the early part of ventricular repolarization. It starts at the end of the QRS complex and ends at the beginning of the T wave. Changes in the ST segment, such as elevation or depression, can indicate myocardial ischemia or injury.
D. The PR interval represents the time it takes for the electrical impulse to travel from the atria to the ventricles. It includes atrial depolarization, atrial contraction, and the delay at the atrioventricular node. The PR interval does not specifically provide information about ventricular depolarization and repolarization.
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