The medical-surgical nurse is caring for a 55-year-old female patient after surgery. The patient's respiratory rate has increased from 12 to 22 breaths/min, and the pulse rate has increased from 86 to 110 beats/min since the patient was last assessed 4 hours ago. What action by the nurse is best?
Assess the patient's tissue perfusion further.
Ask if the patient needs pain medication.
Document the findings in the patient's chart.
Increase the rate of the patient's IV infusion.
The Correct Answer is A
The increased respiratory rate and pulse rate can be indicators of physiological changes or potential complications in the patient's condition. These changes may suggest alterations in tissue perfusion or other underlying issues that require further assessment.
Assessing the patient's tissue perfusion includes evaluating additional vital signs, such as blood pressure, oxygen saturation, and capillary refill time. Assessing skin color, temperature, and moisture, as well as peripheral pulses, can also provide important information regarding tissue perfusion.
B. Pain medication (option B) is incorrect because the increased respiratory and pulse rates could also indicate other factors that require assessment before administering pain medication.
C. Documenting the findings in the patient's chart (option C) is incorrect because it should not be the primary action at this point. Assessing the patient's condition and determining appropriate interventions take priority.
D. Increasing the rate of the patient's IV infusion (option D) is incorrect because may not be the most appropriate action without further assessment. The patient's increased respiratory and pulse rates may not necessarily be related to hydration status, and it is important to assess the patient comprehensively before making changes to the IV infusion rate.
Therefore, the best action by the nurse in this situation is to further assess the patient's tissue perfusion to gather more information and determine the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Norepinephrine is a potent vasoconstrictor and inotropic agent commonly used to increase blood pressure in cases of hypotension or shock. However, if the infusion rate is too high, it can lead to excessive vasoconstriction and potentially compromise organ perfusion.
A heart rate of 58 beats/min suggests bradycardia, which can be an indication of excessive vasoconstriction caused by a high dose or rate of norepinephrine infusion. Excessive vasoconstriction can reduce cardiac output and worsen tissue perfusion.
A. Mean arterial pressure is 55 mm Hg in (option A) is incorrect because A mean arterial pressure of 55 mm Hg may be within an acceptable range for a patient receiving norepinephrine infusion, depending on the patient's baseline blood pressure and clinical condition.
B. Systemic vascular resistance (SVR) is elevated in (option B) is incorrect because An elevated SVR indicates increased peripheral vascular resistance and can be a desired effect of norepinephrine infusion to improve blood pressure and perfusion.
C. Pulmonary artery wedge pressure (PAWP) is low in (option C) which is incorrect because A low PAWP may indicate decreased left ventricular preload, which can be a desired effect of norepinephrine infusion to reduce fluid overload in certain clinical conditions.
It is important for the nurse to carefully monitor the patient's hemodynamic parameters, including blood pressure, heart rate, and organ perfusion when titrating norepinephrine infusion to ensure optimal dosing and minimize potential adverse effects. If concerns arise regarding the infusion rate, the healthcare provider should be promptly notified for further evaluation and adjustment of the treatment plan.
Correct Answer is B
Explanation
The patient's symptoms of fever and elevated white blood cell count suggest a potential infection and sepsis. Broad-spectrum antibiotics should be initiated promptly to cover a wide range of possible pathogens until further diagnostic tests and identification of the specific causative agent are obtained. Early administration of appropriate antibiotics is crucial in sepsis management to target the suspected infection and improve patient outcomes.
A. Cooling baths in (option A) is incorrect because: Cooling baths are typically used in the management of hyperthermia or specific conditions like heatstroke. While the patient has an elevated temperature, it is likely due to the systemic inflammatory response rather than solely hyperthermia.
C. Blood transfusion in (option C) is incorrect because Blood transfusion may be required in certain cases of sepsis if there is evidence of significant anemia or active bleeding. However, based on the information provided, there is no immediate indication of a blood transfusion.
D. NPO status in (option D) is incorrect because NPO status (nothing by mouth) is a general precautionary measure used in various situations, such as prior to surgery or to manage gastrointestinal complications. It is not a specific intervention in the sepsis resuscitation bundle.
Therefore, the nurse should initiate the intervention of administering broad-spectrum antibiotics in this scenario.

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