An immunocompromised older adult has developed a urinary tract infection, and the healthcare team recognizes the need to prevent an exacerbation of the client's infection that could result in sepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock?
Insert a new indwelling urinary catheter
Collect blood cultures
Initiate intravenous (IV) antibiotics
Obtain placement of an intravenous access for fluid administration
The Correct Answer is C
A. Inserting a new indwelling urinary catheter could introduce new pathogens and increase the risk of infection rather than reduce it. Indwelling catheters are a known risk factor for urinary tract infections and should be avoided if possible.
B. Collecting blood cultures is an important diagnostic step, especially if sepsis is suspected. However, this action alone does not directly reduce the risk of septic shock. It is a part of the process but not the most immediate intervention.
C. Initiating intravenous (IV) antibiotics is the most critical intervention to reduce the risk of septic shock. Prompt administration of antibiotics can help control the infection before it progresses to sepsis, making this the priority action.
D. Obtaining placement of an intravenous access for fluid administration is necessary for managing sepsis or septic shock, but the first step should be administering antibiotics to treat the infection causing the sepsis. Fluid administration supports blood pressure and circulation but does not directly address the underlying infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important for individuals with SLE, maintaining an overly cold environment can also trigger symptoms, as cold temperatures can lead to vasoconstriction and Raynaud's phenomenon, which is common in SLE patients.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is an essential component of managing SLE. This indicates that the client understands the importance of medication adherence in controlling the disease.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is a known exacerbating factor for SLE. This statement reflects the client's understanding of the need to reduce stress to prevent flare-ups.
D. Wearing protective clothing when going outside is important because UV light exposure can trigger SLE exacerbations. This shows that the client is aware of the need to protect their skin from sunlight.
Correct Answer is C
Explanation
A. An HbA1c level of 7.5% indicates suboptimal long-term glucose control. The target for many diabetic patients is usually below 7%, but it may not require immediate action compared to more acute indicators.
B. A 2-hour post-prandial blood glucose level of 122 mg/dL is slightly above the normal range but not significantly high. This result alone is not as indicative of inadequate control as other values.
C. A random blood glucose level of 300 mg/dL is significantly elevated and indicates poor glucose control. This value is much higher than the normal range and suggests a need for further teaching and adjustment of diabetes management.
D. A fasting blood glucose level of 48 mg/dL is low and could indicate hypoglycemia rather than inadequate control. This level requires immediate attention but does not reflect poor long-term diabetes management.
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