A nurse is caring for an adolescent who has been admitted to the PICU with a diagnosis of septic shock. The nurse notes the following :
When planning care for this client, the nurse should anticipate a provider's prescription for which of the following?
Broad-spectrum antibiotics and fluid boluses
Antipyretics and oxygen therapy
Vasopressors and blood transfusions
Corticosteroids and antihistamines
The Correct Answer is A
Choice A reason: Broad-spectrum antibiotics are indicated for septic shock caused by bacterial infection, as they can target a wide range of pathogens and prevent further sepsis. Fluid boluses are also essential to restore the intravascular volume and improve tissue perfusion and oxygenation.
Choice B reason: Antipyretics and oxygen therapy are not sufficient to treat septic shock, as they do not address the underlying infection or the hypovolemia. Antipyretics may lower the temperature, but they do not eliminate the bacteria. Oxygen therapy may improve the pulse oximeter reading, but it does not correct the hypoperfusion.
Choice C reason: Vasopressors and blood transfusions are not the first-line treatments for septic shock, as they may have adverse effects on the cardiovascular system and the coagulation cascade. Vasopressors may increase the blood pressure, but they may also cause vasoconstriction and reduce the blood flow to vital organs. Blood transfusions may increase the hemoglobin level, but they may also increase the risk of fluid overload, hemolysis, and transfusion reactions.
Choice D reason: Corticosteroids and antihistamines are not indicated for septic shock, as they do not have any proven benefits and may have harmful effects on the immune system and the inflammatory response. Corticosteroids may suppress the adrenal function and increase the risk of infection. Antihistamines may cause sedation and dryness of the mucous membranes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Balancing the scale to 0 prior to use is a correct action for the nurse to take. This ensures that the scale is accurate and does not include any extra weight from the scale itself or any objects on it.
Choice B reason: Using a stadiometer to measure the infant is not a correct action for the nurse to take. A stadiometer is a device that measures the height of a standing person. It is not suitable for measuring the length of an infant who cannot stand. The nurse should use a measuring board or a tape measure to measure the infant's length.
Choice C reason: Placing a disposable covering on the scale is a correct action for the nurse to take. This prevents the transmission of germs or dirt from the scale to the infant or vice versa. It also protects the scale from any urine or stool that the infant may produce during the weighing.
Choice D reason: Weighing the infant in a diaper is not a correct action for the nurse to take. A diaper can add extra weight to the infant's measurement and affect the accuracy of the result. The nurse should weigh the infant without any clothing or diaper.
Choice E reason: Measuring the infant from crown of the head to the heels of feet is a correct action for the nurse to take. This is the standard method of measuring the length of an infant. The nurse should place the infant on a flat surface, align the head with the top of the measuring board or tape measure, and extend the legs fully. The nurse should then read the measurement at the bottom of the infant's feet.
Correct Answer is C
Explanation
Choice A reason: Failure to thrive is not a likely condition, as it is a term used to describe inadequate growth or weight gain in children. The infant has a low weight percentile, but not below the 5th percentile, which is the usual cutoff for failure to thrive. The infant's length and head circumference are within the normal range, which also does not indicate failure to thrive.
Choice B reason: Microcephaly is not a probable condition, as it is a condition where the head size is much smaller than normal for the age and sex of the child. The infant has a high head circumference percentile, which is the opposite of microcephaly. Microcephaly can be caused by genetic disorders, infections, or brain damage.
Choice C reason: Hydrocephalus is a possible condition, as it is a condition where excess cerebrospinal fluid accumulates in the brain, causing increased pressure and enlargement of the head. The infant has a high head circumference percentile, which can indicate hydrocephalus. The infant also has a low weight percentile, which can be a result of poor feeding or vomiting due to increased intracranial pressure. T
Choice D reason: Macrocephaly is not a definite condition, as it is a term used to describe a head size that is much larger than normal for the age and sex of the child. The infant has a high head circumference percentile, but not above the 97th percentile, which is the usual cutoff for macrocephaly. Macrocephaly can be caused by genetic factors, benign familial macrocephaly, or other conditions, such as hydrocephalus.
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