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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
These statements reflect the appropriate knowledge related to iron deficiency anemia. Iron-rich foods such as meat and beans can help increase iron levels in the body. Vitamin C aids in the absorption of iron, so taking a Vitamin C supplement can enhance iron absorption. Iron deficiency anemia is more common during pregnancy or menstruation due to increased iron demands.
However, increasing intake of dairy products alone does not address the iron deficiency. The statement about oral supplements not being as effective as monthly subcutaneous injections is incorrect, as oral iron supplements are commonly used to treat iron deficiency anemia and are effective in most cases.
Correct Answer is C
Explanation
Pneumonia is an infection that causes inflammation in the lungs. Auscultation refers to listening to the sounds produced by the lungs using a stethoscope. Ronchi and fine crackles are abnormal lung sounds that can be heard during auscultation in individuals with pneumonia.
These sounds are associated with the presence of fluid or mucus in the lungs, which is characteristic of pneumonia.
While other symptoms such as a sore throat, tympany noted on chest percussion, and a slightly elevated temperature (37.8 degrees Celsius) can be present in various respiratory conditions, the auscultation findings of ronchi or fine crackles specifically suggest an underlying lung infection like pneumonia.
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