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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Intravenous fluid administration is anticipated as hydration can help reduce the viscosity of sickled cells, improving circulation and potentially reducing vaso-occlusive events.

Ice packs to the affected area are nonessential and could potentially be contraindicated, as cold can cause vasoconstriction and may exacerbate pain.

Ambulation is nonessential during acute pain episodes and should be encouraged when the patient is comfortable and pain is controlled.

Hydromorphone IV for pain is anticipated because it is a stronger opioid than morphine and may be necessary if the pain is unresponsive to oral morphine sulfate.

Acetaminophen PO for pain is nonessential in this scenario as it is unlikely to provide adequate pain relief for severe vaso-occlusive pain.

Oxygen therapy is nonessential given the client's SpO2 is 95% on room air, indicating adequate oxygen saturation; however, it may be considered if there is evidence of hypoxia or respiratory distress. It is crucial to monitor the client's response to pain management interventions and adjust the treatment plan accordingly.

A. "I will keep the temperature in my house cold to avoid becoming overheated." B. "I will follow my prescribed medication regimen and inform my healthcare provider of any side effects." C. "I will try to manage my stress levels through relaxation techniques and therapy." D. "I will make sure to wear protective clothing when I go outside."

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain. Exhibits For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?

Correct Answer is A

Explanation

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