A patient with septic shock 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 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Acetaminophen (Tylenol) 650 mg rectally.

Start insulin drip to maintain blood glucose at 110 to 150 mg/dl.

Administer normal saline IV at 500 mL/hr.

Start norepinephrine to keep blood pressure above 90 mm Hg.

Answer and Explanation

The Correct Answer is C

C. The first intervention should be to administer normal saline IV at 500 mL/hr to address the immediate concern of hypotension and inadequate tissue perfusion.

A. While fever control is important, especially in septic shock, administering acetaminophen should not be the first intervention in a patient with severe hypotension and shock. Addressing the low blood pressure and perfusion is a higher priority.

B. Hyperglycemia is common in critically ill patients, including those with septic shock. However, in this scenario, the patient's severely low blood pressure and signs of shock take precedence over managing hyperglycemia. Insulin therapy can be initiated later once the patient's hemodynamic status is stabilized.

D. Norepinephrine is a vasopressor medication commonly used in septic shock to increase blood pressure and improve perfusion to vital organs. It helps counteract the vasodilation and hypotension characteristic of septic shock.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Chronic hypertension is a significant risk factor for the development of various cardiac diseases, including coronary artery disease, left ventricular hypertrophy, heart failure, and arrhythmias. The increased workload on the heart caused by hypertension can lead to myocardial remodeling, impaired cardiac function, and ultimately heart disease.

B. Chronic hypertension can cause damage to the kidneys over time, leading to renal insufficiency or chronic kidney disease. The elevated blood pressure damages the delicate blood vessels in the kidneys, impairing their ability to filter waste products and regulate fluid and electrolyte balance. Persistent hypertension can ultimately lead to kidney dysfunction and renal failure.

C. Hypertension is a major risk factor for the development of stroke, particularly ischemic stroke (caused by a blockage in a blood vessel supplying the brain) and hemorrhagic stroke (caused by bleeding into the brain). Chronic hypertension can damage blood vessels in the brain, leading to the formation of blood clots or weakening of vessel walls, increasing the risk of stroke.

E. Chronic hypertension is a significant risk factor for the development of atrial fibrillation, a type of irregular heart rhythm characterized by rapid and chaotic electrical activity in the upper chambers of the heart (atria). The structural changes in the heart caused by hypertension, such as left atrial enlargement and fibrosis, can predispose individuals to atrial fibrillation.

D. Familial hypercholesterolemia is a genetic disorder characterized by high levels of LDL cholesterol in the blood. While chronic hypertension itself does not directly cause familial hypercholesterolemia, hypertension and hypercholesterolemia are often comorbid conditions that contribute to cardiovascular risk. Both conditions can lead to atherosclerosis, increasing the risk of heart disease and stroke.

F. Isolated systolic hypertension refers to elevated systolic blood pressure with normal diastolic blood pressure. While isolated systolic hypertension itself is a manifestation of hypertension, it is not a direct result of end-organ damage. However, if left untreated, isolated systolic hypertension can lead to complications such as stroke, heart failure, and kidney disease, which are consequences of end-organ damage from chronic hypertension.

A. Check the tubing connections for leaks. B. Continue to monitor the client's respiratory status. C. Check the suction control outlet on the wall. D. Clamp the chest tube.

Correct Answer is B

Explanation

B. In a closed chest drainage system, slow and steady bubbling in the suction control chamber is typically an expected finding, as it indicates that the suction is active and functioning properly

A. Checking the tubing connections for leaks or the suction control outlet on the wall might be necessary if there were signs of a problem with the system's function.

C. Checking the suction control outlet on the wall is a reasonable action to ensure that the suction source is functioning appropriately and delivering the prescribed suction pressure to the chest drainage system. If there are any issues with the suction control outlet, they should be addressed to maintain proper suction.

D. Clamping the chest tube is not indicated based solely on the presence of slow, steady bubbling in the suction control chamber. Clamping the chest tube could obstruct drainage and lead to complications such as tension pneumothorax or retained hemothorax.

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A patient with septic shock 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 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is(are) potential result(s) of end-organ damage from chronic hypertension? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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