A patient has been diagnosed with septic shock.
What collaborative interventions would be expected? (Select all that apply)
Temperature control for either hypothermia or hyperthermia.
Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine.
Administration of a thrombolytic (streptokinase).
Subcutaneous administration of epinephrine (1:1000) 0.5 to 1 ml every 5 to 15 minutes.
Blood cultures from all suspected sources before administration of antibiotics.
Vigorous intravenous fluid resuscitation with 0.9% sodium chloride.
Correct Answer : A,B,E,F
Choice A rationale:
Temperature control for either hypothermia or hyperthermia is crucial in septic shock management. Here's a detailed explanation:
Hypothermia:
Mechanism: Septic shock often causes impaired thermoregulation, leading to hypothermia. It can worsen shock by decreasing cardiac output, impairing coagulation, and promoting vasoconstriction.
Intervention: Active warming measures are essential, including: External warming devices (e.g., blankets, forced air warmers) Intravenous fluids warmed to 39-42°C
Warmed humidified oxygen
Minimizing exposure and covering the patient Hyperthermia:
Mechanism: Sepsis can trigger an excessive inflammatory response, leading to hyperthermia. It can exacerbate tissue injury, increase metabolic demands, and worsen organ dysfunction.
Intervention: Aggressive measures to lower temperature are necessary, including:
Antipyretic medications (e.g., acetaminophen, ibuprofen) External cooling methods (e.g., cooling blankets, ice packs) Sedation if shivering occurs
Choice B rationale:
Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine is often required in septic shock to: Improve cardiac output: These agents increase myocardial contractility and heart rate, enhancing blood flow to vital organs.
Maintain blood pressure: They support vasoconstriction, counteracting the widespread vasodilation characteristic of septic shock.
Improve tissue perfusion: By optimizing cardiac output and blood pressure, they help ensure adequate oxygen and nutrient delivery to tissues.
Choice E rationale:
Blood cultures from all suspected sources before administration of antibiotics are essential for guiding appropriate antibiotic therapy.
Early identification of the causative organism: This information is crucial for selecting the most effective antibiotic regimen.
Prevention of antibiotic resistance: Judicious use of antibiotics based on culture results helps prevent the development of antibiotic-resistant bacteria.
Choice F rationale:
Vigorous intravenous fluid resuscitation with 0.9% sodium chloride is a cornerstone of septic shock management.
Replenishing intravascular volume: Septic shock often causes profound intravascular volume depletion due to capillary leak and vasodilation. Fluid resuscitation aims to restore circulating volume and maintain organ perfusion.
Improving hemodynamic stability: By increasing preload and cardiac output, fluids help stabilize blood pressure and support vital organ function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This response is dismissive of the patient's pain and does not offer any assistance. It also does not acknowledge the patient's concerns about their pain being a normal part of aging.
It's important to validate the patient's experience and offer support, even if the pain level is not severe.
This response could lead to the patient feeling unheard and unsupported, and it could potentially delay necessary treatment.
Choice B rationale:
This response suggests that the patient's pain is not significant enough to warrant treatment unless it worsens. This is not appropriate, as pain is subjective and should be treated based on the patient's individual experience.
Additionally, this response reinforces the patient's belief that pain is a normal part of aging, which may prevent them from seeking treatment in the future.
Choice C rationale:
This response is the best option because it acknowledges the patient's pain, expresses concern, and suggests further investigation.
It is important to rule out any underlying medical conditions that may be causing the pain.
This response also demonstrates to the patient that the nurse is taking their pain seriously and is committed to helping them manage it.
Choice D rationale:
This response acknowledges that pain can be a part of aging, but it also suggests that there may be a specific cause for the patient's pain.
This could lead to the patient feeling anxious or worried about their health.
It is important to investigate the cause of the pain before making any assumptions.
Correct Answer is A
Explanation
Choice A rationale:
It is crucial for the nurse to prioritize patient safety and adhere to professional guidelines when encountering a potential diversion of controlled substances. Informing the charge nurse is the most appropriate initial action for several reasons:
Chain of Command: The charge nurse holds a supervisory position and is responsible for addressing issues within the unit, including concerns about medication diversion. Reporting suspicions to the charge nurse ensures adherence to the established chain of command and facilitates a prompt, organized response.
Confidentiality and Objectivity: The charge nurse is trained to handle sensitive situations discreetly and objectively. They can initiate a thorough investigation while maintaining confidentiality and protecting the rights of all involved parties.
Access to Resources: The charge nurse has access to resources and authority to take immediate action, such as securing medications, initiating patient assessments, and notifying appropriate personnel within the healthcare facility.
Collaboration and Support: The charge nurse can provide guidance and support to the reporting nurse, ensuring their concerns are addressed appropriately and that they feel safe in coming forward with their suspicions.
Rationale for other choices:
B. Reporting the incident directly to the hospital’s security department might be premature without first informing the charge nurse. The charge nurse can assess the situation, gather more information, and determine the most appropriate course of action, which may or may not involve security at this initial stage.
C. Requesting assistive personnel (AP) to monitor the other nurse’s actions is inappropriate. It places a burden on APs who are not trained or authorized to investigate such matters. It could also compromise the integrity of the investigation and potentially jeopardize patient safety.
D. Confronting the other nurse directly is not recommended. It could escalate the situation, create a hostile work environment, and potentially compromise the investigation. It is essential to follow established protocols and involve appropriate personnel to ensure a fair and thorough investigation.
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