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The initial bundle of care in sepsis includes which of the following? (Select all that apply.)

Administer anti-hypertensives

Obtain blood cultures

Administer broad spectrum antibiotics

Obtain lactate levels

Administer IV fluid bolus

Answer and Explanation

Correct Answer : B,C,D,E

The initial bundle of care in sepsis includes the following:

Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.

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Correct Answer is A

Explanation

A. Notify the surgeon that the informed consent process is not complete.The nurse should inform the surgeon because the surgeon is responsible for ensuring that the patient has adequate information and understands the procedure. It is not appropriate for the nurse to proceed with the consent process if the patient has questions or uncertainties.

B. Notify the operating room nurse to give a more complete explanation of the procedure.While the operating room nurse plays a role in the surgical process, it is the surgeon’s responsibility to provide a complete explanation of the procedure.

C. Provide a thorough explanation of the planned surgical procedure.While it’s important to provide information, the nurse is not authorized to explain the surgical procedure in detail. The surgeon should explain the surgery, as they have the training and knowledge to address all aspects of the procedure and answer any specific questions.

D. Give the prescribed preoperative antibiotics and withhold sedative medications.Administering preoperative medications, including antibiotics, without completed informed consent would be inappropriate. The patient must fully understand the procedure and consent to it before any medications are given.

A. "The red blood cell count should begin to improve with these injections B. "My Cr and BUN will slowly improve over the next 7-10 days. C. I will not have to take Furosemide any longer. D. Urine output should improve with these injections.

Correct Answer is A

Explanation

Recombinant human erythropoietin is a medication commonly used in the treatment of anemia associated with chronic renal failure. It stimulates the production of red blood cells in the bone marrow, helping to improve anemia.

The other statements mentioned do not accurately reflect the expected outcomes or effects of recombinant human erythropoietin:

Chronic renal failure leads to impaired kidney function, and while recombinant human erythropoietin can help address anemia, it does not directly improve creatinine (Cr) and blood urea nitrogen (BUN) levels, which are markers of kidney function.

Furosemide is a diuretic commonly used in the management of fluid retention in renal failure. Recombinant human erythropoietin does not replace or eliminate the need for diuretic therapy.

Chronic renal failure typically involves decreased kidney function and impaired urine production. Recombinant human erythropoietin does not directly affect urine output.

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The initial bundle of care in sepsis includes which of the following? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

Correct Answer is A

Explanation

The nurse is teaching a client with chronic renal failure (CRF) about the use of recombinant human erythropoietin (Epogen) Subcutaneous injections. Which statement indicates the client understands the teaching?

Correct Answer is A

Explanation

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