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A nurse is caring for a 73-year-old male 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.

Obtain a wound culture

Rapidly administer 30 mL/kg of normal saline

Insert a nasogastric (NG) tube

Obtain blood cultures

Administer broad-spectrum antibiotics

Measure lactate level

Type and cross-match for 2 units of packed RBCs

Obtain a urine specimen

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale:

Obtaining a wound culture is crucial to identify the causative organism and guide appropriate antibiotic therapy. Prompt identification and treatment of the infection source can prevent further systemic complications.

Choice B rationale:

Rapidly administering 30 mL/kg of normal saline helps to restore intravascular volume, improve hemodynamic stability, and enhance tissue perfusion. This intervention is vital in the initial management of sepsis to prevent organ dysfunction.

Choice D rationale:

Obtaining blood cultures before initiating antibiotic therapy is essential to identify the causative microorganism and tailor antibiotic treatment. This step ensures accurate diagnosis and effective management of sepsis.

Choice E rationale:

Administering broad-spectrum antibiotics as soon as possible is critical in managing sepsis. Early and appropriate antibiotic therapy significantly reduces mortality and morbidity by targeting the suspected pathogens promptly.

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Correct Answer is []

Explanation

The client has respiratory acidosis as indicated by a pH of 7.25 (normal: 7.35-7.45) and elevated pCO2 of 62 mm Hg (normal: 35-45 mm Hg). This condition occurs when the lungs cannot remove enough CO2, leading to its buildup and lowering the blood pH. Immediate interventions like intubation can help manage airway and ventilation. Starting an IV drip of 0.9% sodium chloride can help address dehydration, supporting hemodynamic stability. Monitoring the correct placement of the endotracheal tube ensures effective ventilation. Regular arterial blood gases assessment helps evaluate the effectiveness of interventions and the client's respiratory status.

Prepare the client for intubation: Intubation is essential to secure the airway and provide mechanical ventilation, addressing hypoxia and hypercapnia by improving gas exchange.

Start a 0.9% sodium chloride IV drip: This fluid helps in correcting dehydration, supporting blood pressure, and improving renal perfusion, which is critical in managing acid-base balance.

Correct placement of endotracheal tube: Ensuring the tube is in the correct position guarantees effective ventilation and prevents complications such as aspiration or pneumothorax.

Arterial blood gases: Regular ABG assessments help monitor the effectiveness of ventilation and guide adjustments in therapy, ensuring the client’s acid-base balance is maintained.

Metabolic acidosis is not correct as the primary issue here is a respiratory one, indicated by elevated pCO2 and lower pH.

Respiratory alkalosis is incorrect as it would present with a high pH and low pCO2, unlike the client's findings.

Metabolic alkalosis is ruled out because it would show elevated pH and bicarbonate levels, which is not seen in the client's ABG results.

A. Your HbA1c level of 5.7% or below indicates you have impaired glucose tolerance. B. Since you still have working beta cells, you can try diet to lower your blood sugar. C. This can be a reversible condition, so we will discuss ways to improve your health. D. This type of diabetes means that the cells in your pancreas do not produce any insulin.

Correct Answer is D

Explanation

Choice A rationale

An HbA1c level of 5.7% or below indicates normal glucose tolerance, not impaired glucose tolerance.

Choice B rationale

In type 1 diabetes mellitus, the beta cells are destroyed, and dietary changes alone cannot restore insulin production.

Choice C rationale

Type 1 diabetes mellitus is a chronic condition and is not considered reversible.

Choice D rationale

Type 1 diabetes mellitus is characterized by the autoimmune destruction of beta cells in the pancreas, leading to an absolute lack of insulin production.

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A nurse is caring for a 73-year-old male 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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Correct Answer is []

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Correct Answer is D

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A nurse is caring for a 73-year-old male 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.