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 C
Explanation
The glomerular filtration rate is a measure of how effectively the kidneys filter waste and excess fluid from the blood. It is a key indicator of kidney function. CKD is staged based on the GFR, which provides an estimate of the percentage of normal kidney function remaining.
While serum creatinine and urea levels are important markers used to assess kidney function, they are not the sole criteria for staging CKD. The degree of altered mental status and total daily urine output are important clinical observations but are not used for staging CKD.
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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