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. 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.
Correct Answer is B
Explanation
B. Right-sided heart failure leads to congestion of the systemic venous circulation, resulting in increased central venous pressure (CVP). Elevated CVP is a hallmark sign of right-sided heart failure and is often used clinically to assess right ventricular preload and volume status.
A. BNP is a hormone secreted by the heart in response to increased ventricular stretch and volume overload, and its levels are usually elevated in heart failure, including both left-sided and right-sided heart failure.
C. Specific gravity refers to the concentration of solutes in urine and is often used as a measure of urine concentration.
D. Pulmonary artery wedge pressure (PAWP) is a measure of left atrial pressure and left ventricular end- diastolic pressure. In right-sided heart failure, the primary hemodynamic abnormality is congestion of the systemic venous circulation, rather than elevated left-sided pressures.
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