A patient with sepsis has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 245 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Give 0.9% Sodium Chloride fluid bolus.

Give Pantoprazole (Protonix 40 mg IV push dally.

Give Acetaminophen (Tyler) 550 mg rectally.

Give rapid acting insulin per sliding scale.

Answer and Explanation

The Correct Answer is A

The patient's vital signs indicate signs of septic shock, including low blood pressure (70/46 mm Hg), tachycardia (136 beats/min), and tachypnea (32 breaths/min). The patient also has a high temperature of 104°F, indicating a fever. These findings suggest a systemic response to an infection that is leading to inadequate tissue perfusion.The initial treatment for septic shock includes fluid resuscitation to improve blood pressure and tissue perfusion. A fluid bolus of 0.9% Sodium Chloride (normal saline) is commonly used to restore intravascular volume in septic shock. It helps to increase blood pressure, improve organ perfusion, and stabilize the patient's condition.

The other interventions, such as administering Pantoprazole (Protonix) for gastrointestinal protection, giving Acetaminophen (Tylenol) for fever control, or administering rapid-acting insulin per sliding scale for hyperglycemia, are important aspects of care but should be implemented after the initial fluid resuscitation. The priority at this moment is to address the patient's hypotension and inadequate tissue perfusion through the administration of fluid bolus.

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Correct Answer is A

Explanation

The signs or symptoms the nurse would observe in a 4-year-old client experiencing a recurrence of minimal change nephrotic syndrome (MCNS) include:

MCNS is characterized by increased glomerular permeability, leading to the loss of protein, particularly albumin, in the urine. Proteinuria is a hallmark feature of MCNS and is usually detected through urine testing.
Due to the excessive loss of protein in the urine, particularly albumin, the client with MCNS may have low levels of albumin in the blood. Hypoalbuminemia can result in various complications, such as edema formation and impaired immune function. However this is not a sign or symptom.
Edema is a common symptom of MCNS and typically presents as swelling in the face, around the eyes, and in the extremities. This is a result of the fluid shifts and fluid retention caused by the altered glomerular function and hypoalbuminemia.

Hypocalcemia and ketones in the urine are not typically associated with MCNS. Hypocalcemia can occur in some types of kidney disease, but it is not a characteristic feature of MCNS. Ketones in the urine are more commonly associated with conditions like diabetic ketoacidosis or inadequate carbohydrate intake.

A. Blood pressure due to the vasoconstriction action of this medication. B. Intake/output due to the diuretic action of this medication. C. Blood pressure due to the vasodilation action of this medication. D. Peripheral pulses due to the vasoconstriction action of this medication.

Correct Answer is C

Explanation

Nitroprusside is a potent vasodilator medication used to rapidly reduce blood pressure in hypertensive emergencies. Its primary action is to dilate blood vessels, leading to a decrease in systemic vascular resistance and subsequent reduction in blood pressure.

Monitoring the client's blood pressure is crucial during the administration of nitroprusside to ensure that the medication is achieving the desired effect and that blood pressure is being appropriately controlled. The nurse will assess blood pressure frequently to adjust the infusion rate and titrate the medication to achieve the desired therapeutic effect while avoiding hypotension or other adverse effects.

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A patient with sepsis has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 245 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse suspects the 4-year-old client is having a recurrence of minimal change nephrotic syndrome (MCNS). Which signs or symptoms would the nurse observe in the client?

Correct Answer is A

Explanation

The nurse is administering nitroprusside by IV infusion for a client in hypertensive emergency. The nurse knows that the primary assessment will be:

Correct Answer is C

Explanation

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