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 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.
Correct Answer is B
Explanation
The given observations suggest the occurrence of malignant hyperthermia (MH), a potentially life-threatening reaction to certain medications used during anesthesia. MH is characterized by an increase in heart rate (tachycardia), elevated body temperature (hyperthermia), and muscle rigidity. The primary treatment for MH is the administration of dantrolene, which is a skeletal muscle relaxant that helps to counteract the effects of the reaction.
Naloxone (Narcan) is an opioid receptor antagonist used to reverse the effects of opioid overdose or excessive opioid sedation.
Furosemide (Lasix) is a diuretic used to treat conditions such as edema and high blood pressure.
Flumazenil (Romazicon) is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose or excessive sedation.
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