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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 C

Explanation

C Dyspnea, or difficulty breathing, is a classic symptom of circulatory overload. When the circulatory system is overloaded with excess fluid, it can lead to pulmonary congestion and impaired gas exchange, resulting in dyspnea. Patients experiencing circulatory overload may exhibit signs such as shortness of breath, increased respiratory rate, and crackles on lung auscultation.

A Flushing, or the sudden reddening of the skin, is not typically associated with circulatory overload. Instead, it can be a symptom of various conditions such as fever, allergic reactions, or hormonal changes. While circulatory overload may lead to fluid retention and increased blood volume, flushing is not a characteristic symptom.

B Vomiting is also not a typical symptom of circulatory overload. Vomiting can be caused by various factors such as anesthesia, pain medications, or postoperative ileus. While fluid overload can result in gastrointestinal symptoms like nausea and abdominal discomfort, vomiting is not a specific indicator of circulatory overload.

D Bradycardia, or a slow heart rate, is not typically associated with circulatory overload. Instead, it can be caused by factors such as medications (e.g., opioids, beta-blockers), vagal stimulation, or underlying cardiac conditions. In circulatory overload, the body's compensatory response is often tachycardia (increased heart rate) rather than bradycardia.

A. Prepare to insert a central line. B. Administer oxygen via nasal cannula. C. Raise the foot of the bed to a 90° angle. D. Remove the dressing to inspect the wound.

Correct Answer is B

Explanation

B. This is a reasonable action given the client's respiratory rate and potential hypoxemia resulting from the sucking chest wound. Providing supplemental oxygen can help improve oxygenation and support the client's respiratory effort. However, it doesn't directly address the underlying cause of the shock.

A. In this scenario, the client's vital signs indicate signs of shock, which could be due to significant blood loss from the sucking chest wound. While inserting a central line may be necessary for administering fluids and medications rapidly, it's not the immediate priority in this situation. Stabilizing the client's condition takes precedence.

C. Elevating the foot of the bed to a 90° angle is not appropriate in this situation. This position can further decrease venous return to the heart, potentially exacerbating the client's hypotension and shock. It's crucial to maintain a neutral or slightly elevated position to optimize venous return.

D. While it's important to assess the wound and monitor for any changes, removing the dressing on a sucking chest wound without appropriate precautions can worsen the client's condition. The dressing helps to maintain a seal over the wound, preventing further air from entering the pleural space and worsening the tension pneumothorax. Removing the dressing should be done cautiously and preferably by a healthcare provider trained in managing chest trauma.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

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?