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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 C

Explanation

Choice A rationale

Acetaminophen can be hepatotoxic in clients with liver damage, so it should be avoided. This is especially critical for clients with cirrhosis, where liver function is already compromised.

Choice B rationale

Eating three large meals can be overwhelming for someone with cirrhosis, as the liver is less able to process nutrients efficiently. Smaller, more frequent meals are advised.

Choice C rationale

Avoiding high-sodium foods is crucial because cirrhosis often leads to fluid retention and ascites, which can be exacerbated by a high-sodium diet.

Choice D rationale

Increasing activity as much as possible may not be safe for someone with cirrhosis, who often experiences fatigue and muscle wasting. Activity should be balanced with rest and tolerance levels.

A. Discuss the manifestations of hyperglycemia with the parents. B. Teach the parents about cortisol replacement therapy. C. Place the child on a low-sodium diet. D. Monitor the child for fluid volume excess.

Correct Answer is B

Explanation

Choice A rationale

Discussing hyperglycemia manifestations is not specific to Addison's disease, as Addison's is characterized by hypoglycemia due to cortisol deficiency.

Choice B rationale

Teaching the parents about cortisol replacement therapy is essential in Addison's disease management. Cortisol deficiency is the primary issue, so educating on proper administration and monitoring is crucial.

Choice C rationale

Placing the child on a low-sodium diet is not recommended because Addison's disease often involves salt wasting, so adequate sodium intake is necessary.

Choice D rationale

Monitoring for fluid volume excess is more applicable to conditions like heart failure, not Addison's disease, which is associated with dehydration and hypovolemia.

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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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Naxlex Comprehensive Predictor Exams

A nurse is preparing discharge instructions for a client who has cirrhosis of the liver.Which of the following statements should be included in the education materials?

Correct Answer is C

Explanation

A nurse is caring for a child who has Addison's disease.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 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.

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis? (Select all that apply.)

A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following actions should the nurse take first?

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.