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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Pain and coldness in the fingers following AVG placement can indicate impaired blood flow or compromised circulation to the hand. This may be due to complications such as thrombosis (clot formation), graft malfunction, or decreased arterial perfusion. These symptoms should be taken seriously and promptly communicated to the healthcare provider.
The healthcare provider needs to evaluate the patient's symptoms, assess the AVG, and determine the appropriate course of action. Prompt intervention can help prevent further complications and ensure adequate blood flow to the fingers.
Correct Answer is C
Explanation
Weight gain is a positive indicator of improved nutritional status. It suggests that the client is receiving adequate nutrition and their body is able to build up and retain weight. This is particularly important in the case of protein-calorie malnutrition, as it indicates that the client is receiving sufficient protein and calories to support their nutritional needs.
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