A nurse is caring for a 73-year-old male client in the emergency department (ED).
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Cyanosis is a late sign of hypoxemia and not the most common initial manifestation of ARDS. It indicates severe oxygen deprivation but doesn’t typically appear first.
Choice B rationale
Diaphoresis, or excessive sweating, can occur with many conditions causing distress, but it’s not specifically the most common presenting symptom of ARDS. It's more of a nonspecific symptom of stress.
Choice C rationale
Somnolence, or drowsiness, might occur in severe respiratory distress when oxygen levels drop significantly, but it’s not the primary or most common presenting manifestation of ARDS.
Choice D rationale
Dyspnea, or difficulty breathing, is the hallmark of ARDS and the most common presenting symptom. It occurs due to the acute onset of severe hypoxemia caused by the underlying pathophysiology of ARDS.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Acidosis is a key characteristic of diabetic ketoacidosis due to the accumulation of ketoacids in the body from fat metabolism.
Choice B rationale
Low blood sugar is not associated with diabetic ketoacidosis; it is characterized by hyperglycemia.
Choice C rationale
Ketosis occurs in DKA due to the breakdown of fats instead of glucose for energy, leading to an accumulation of ketones.
Choice D rationale
Fluid overload is not typical of diabetic ketoacidosis; dehydration is more common due to osmotic diuresis.
Choice E rationale
Hyperglycemia is a hallmark of diabetic ketoacidosis, resulting from the lack of insulin and the consequent high levels of glucose in the blood.
Choice F rationale
Alkalosis is not associated with diabetic ketoacidosis; the condition is defined by metabolic acidosis. .
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