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","E"]
Explanation
Small bowel obstruction can lead to the accumulation of gastric contents above the obstruction, causing vomiting.
Obstruction of the small bowel can result in crampy, colicky abdominal pain and abdominal distention.
Electrolyte imbalances, such as hypokalemia (low potassium), can occur due to vomiting and inadequate intake in cases of small bowel obstruction.
The following finding is not directly associated with small bowel obstruction:
Pain relief after eating is more commonly associated with peptic ulcer disease, not small bowel obstruction.
While blood in the stool can be seen in some cases of bowel obstruction, it is more commonly associated with lower gastrointestinal bleeding or other conditions affecting the colon, rather than small bowel obstruction.
Correct Answer is C
Explanation
Crohn's Disease is an inflammatory bowel disease that can affect any part of the digestive tract. The goal of treatment is to control inflammation, relieve symptoms, and prevent complications. To achieve this, the healthcare provider may prescribe medication such as anti-inflammatory drugs, immunosuppressants, or biologic therapies that target specific inflammatory pathways.
These medications can help reduce inflammation and improve symptoms.
In addition to medication, nutritional therapy may also be recommended to help manage Crohn's Disease. However, dietary restrictions to reduce calorie and fat intake to lose weight or restrict foods containing gluten to control symptoms are not specific treatments for Crohn's Disease.
Keeping the child in isolation to prevent the spread of the infection is not relevant to Crohn's Disease, as it is not contagious.
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