A nurse is planning care for a client who has a new diagnosis of sepsis. Which of the following interventions is the nurse's priority?
Initiate oxygen therapy.
Administer antibiotics.
Obtain blood cultures.
Begin an IV crystalloid infusion.
The Correct Answer is A
A. Initiate oxygen therapy: Sepsis can lead to tissue hypoxia and organ dysfunction due to impaired perfusion. Oxygen therapy is the priority to ensure adequate oxygenation, prevent respiratory failure, and support vital organ function.
B. Administer antibiotics: Broad-spectrum antibiotics are essential to treat the underlying infection, but they should be given after obtaining blood cultures to ensure accurate pathogen identification and prevent delays in appropriate therapy.
C. Obtain blood cultures: Blood cultures must be collected before antibiotic administration to identify the causative organism, but stabilizing the client's oxygenation and perfusion takes precedence in acute management.
D. Begin an IV crystalloid infusion: Fluid resuscitation is crucial for managing septic shock, but oxygen therapy should be initiated first to immediately improve oxygen delivery and prevent hypoxia-related complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiate oxygen therapy: Sepsis can lead to tissue hypoxia and organ dysfunction due to impaired perfusion. Oxygen therapy is the priority to ensure adequate oxygenation, prevent respiratory failure, and support vital organ function.
B. Administer antibiotics: Broad-spectrum antibiotics are essential to treat the underlying infection, but they should be given after obtaining blood cultures to ensure accurate pathogen identification and prevent delays in appropriate therapy.
C. Obtain blood cultures: Blood cultures must be collected before antibiotic administration to identify the causative organism, but stabilizing the client's oxygenation and perfusion takes precedence in acute management.
D. Begin an IV crystalloid infusion: Fluid resuscitation is crucial for managing septic shock, but oxygen therapy should be initiated first to immediately improve oxygen delivery and prevent hypoxia-related complications.
Correct Answer is B
Explanation
A. Wears an N95 mask when providing wound care: MRSA is transmitted via direct contact rather than airborne particles, so an N95 mask is unnecessary unless the client has a secondary airborne infection like tuberculosis. Standard contact precautions, including gloves and gowns, are sufficient to prevent transmission.
B. Wears clean gloves when caring for the client: MRSA requires contact precautions, which include wearing gloves when touching the client or contaminated surfaces. Gloves help prevent the spread of bacteria, particularly from wound drainage, body fluids, or contaminated equipment.
C. Remains 3 feet away from the client: MRSA does not require droplet precautions, which would necessitate maintaining a distance of 3 feet. Instead, direct skin-to-skin contact or contact with contaminated surfaces is the primary mode of transmission, requiring gloves and gowns rather than distance.
D. Disposes of isolation gown outside of the client's room: Isolation gowns should be removed inside the client’s room to prevent cross-contamination. Removing the gown before exiting the room reduces the risk of spreading MRSA to other areas and healthcare personnel.
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