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
Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.
Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.
Correct Answer is B
Explanation
Cushing's syndrome is a disorder characterized by excessive production or prolonged exposure to high levels of glucocorticoids, particularly cortisol. This can occur due to various reasons, such as the use of corticosteroid medications or overproduction of cortisol by the adrenal glands. Elevated glucocorticoid levels result in a variety of clinical manifestations associated with Cushing's syndrome, including weight gain, central obesity, muscle wasting, thinning of the skin, easy bruising, and impaired glucose metabolism.
It's important to note that Cushing's syndrome can have different underlying causes, such as adrenal tumors, pituitary tumors, or ectopic ACTH production. Regardless of the cause, the common feature in Cushing's syndrome is the excessive glucocorticoid levels, which contribute to the signs and symptoms of the condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today