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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 ["Lithotripsy"," Encourage increased fluid intake"]

Explanation

Lithotripsy and Encourage increased fluid intake are the most important interventions.

A. A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain B. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL C. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL D. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%

Correct Answer is B

Explanation

A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.

While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.

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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

What are the most important nursing interventions for clients with possible renal calculi? List two.

Correct Answer is ["Lithotripsy"," Encourage increased fluid intake"]

Explanation

After a change-of-shift report, which client should the nurse assess first?

Correct Answer is B

Explanation

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