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 B
Explanation
A. Fasting blood glucose level: This test provides a snapshot of the client's blood glucose at a single point in time, typically after an overnight fast. While useful for daily monitoring, it does not reflect long-term glycemic control.
B. Glycosylated hemoglobin level: Hemoglobin A1c measures average blood glucose levels over the past 2 to 3 months, making it the most reliable indicator of long-term glycemic control. A target level below 7% is recommended for most individuals with diabetes.
C. Postprandial blood glucose level: This test evaluates blood sugar levels after meals but only provides short-term information about glucose fluctuations rather than an overall picture of glycemic control.
D. Oral glucose tolerance test results: This test is primarily used to diagnose diabetes and gestational diabetes rather than to monitor long-term control in individuals already diagnosed with diabetes.
Correct Answer is B
Explanation
A. A client who has aspiration pneumonia: Pneumonia leads to hypoventilation and carbon dioxide retention, which causes respiratory acidosis. It does not typically result in metabolic alkalosis since it affects gas exchange rather than acid-base balance at the metabolic level.
B. A client who is receiving continuous gastric suctioning: Prolonged removal of gastric secretions depletes hydrochloric acid, leading to an excess of bicarbonate in the blood and resulting in metabolic alkalosis. This is a common cause of alkalosis, along with excessive vomiting or diuretic use.
C. A client who is experiencing an opioid overdose: Opioids depress the respiratory system, reducing ventilation and causing carbon dioxide buildup, leading to respiratory acidosis. This does not cause metabolic alkalosis, as the issue originates in the lungs, not metabolism.
D. A client who has uncontrolled diabetes mellitus: Diabetic ketoacidosis results in excessive production of acidic ketone bodies, which lower blood pH and cause metabolic acidosis. The acid-base disturbance in diabetes is typically acidosis, not alkalosis.
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