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 C
Explanation
Choice A rationale
Temperature of 36.1°C (97.0°F) is below normal range and not indicative of organ rejection. Organ rejection often presents with elevated temperature due to the inflammatory response of the immune system attacking the transplanted organ.
Choice B rationale
Weight loss is not a common sign of acute organ rejection. Usually, fluid retention and associated weight gain can occur due to decreased kidney function.
Choice C rationale
Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.
Choice D rationale
Insomnia is not typically associated with organ rejection. It can be related to stress or other factors but is not a direct sign of rejection.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Hypertension is not a typical manifestation of sepsis; sepsis usually involves hypotension.
Choice B rationale
Hypoglycemia is not a common manifestation of sepsis; hyperglycemia is more typical.
Choice C rationale
Altered mental status can occur due to the systemic inflammation and infection affecting the brain.
Choice D rationale
An elevated WBC count indicates an immune response to infection, which is a common sign of sepsis.
Choice E rationale
Vomiting can occur due to the body's response to the infection and systemic inflammation.
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