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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Insert a urinary catheter: While a urinary catheter may be necessary for monitoring urine output, it does not directly prevent acute kidney failure. Maintaining adequate perfusion and hydration is the primary concern in preventing kidney injury.

B. Prepare the client for an intravenous pyelogram: An intravenous pyelogram (IVP) involves contrast dye, which can be nephrotoxic and potentially worsen kidney function. It is not appropriate in a client at risk for acute kidney injury.

C. Administer IV fluids to the client: Fluid resuscitation helps maintain adequate renal perfusion and prevents hypovolemia-induced acute kidney failure. Clients with significant blood loss are at high risk for prerenal kidney injury due to decreased perfusion.

D. Initiate beta blocker therapy: Beta blockers are used for cardiovascular conditions but do not prevent acute kidney failure. In this situation, maintaining blood volume and renal perfusion is the priority.

A. Palpate the dorsalis pedis pulse. B. Maintain the affected extremity in a dependent position. C. Wrap sterile gauze on the sharp point of the pins. D. Adjust the clamps on the fixator frame.

Correct Answer is A

Explanation

A. Palpate the dorsalis pedis pulse: Assessing distal pulses ensures adequate circulation to the affected extremity. Impaired blood flow can indicate compartment syndrome or vascular compromise, which are serious complications following fracture stabilization. The nurse should also monitor capillary refill, skin temperature, and sensation.

B. Maintain the affected extremity in a dependent position: Keeping the extremity in a dependent position can increase swelling and venous congestion, leading to complications such as compartment syndrome. Elevation is recommended to minimize edema and promote venous return.

C. Wrap sterile gauze on the sharp point of the pins: The pin sites should be left uncovered to allow for proper monitoring of signs of infection or loosening. Instead, pin site care should be performed per facility protocol to reduce infection risk.

D. Adjust the clamps on the fixator frame: Adjusting the external fixator clamps is outside the nurse's scope of practice. Any modifications to the device should be performed by the orthopedic provider to prevent improper alignment and complications.

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