The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2°F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next?

Give the PRN acetaminophen (Tylenol).

Notify the health care provider of these findings.

Obtain oxygen saturation using pulse oximetry.

Give the scheduled IV antibiotic.

Answer and Explanation

The Correct Answer is B

Choice A reason: Acetaminophen reduces fever, but 101.2°F isn’t critical in sepsis, where hypotension (90/56 mmHg) signals shock. Addressing fever alone ignores systemic instability, delaying urgent intervention for a deteriorating patient needing comprehensive management.

Choice B reason: Hypotension (90/56 mmHg) and tachypnea (34 breaths/min) indicate septic shock, requiring immediate escalation. Notifying the provider ensures rapid fluid resuscitation and vasopressors, critical in gram-negative sepsis to reverse hypoperfusion and prevent organ failure.

Choice C reason: Pulse oximetry assesses oxygenation, useful in sepsis with tachypnea. However, hypotension is more immediately life-threatening, prioritizing provider notification for systemic treatment over a single parameter check that delays broader stabilization efforts.

Choice D reason: IV antibiotics target sepsis’s cause, but a scheduled dose doesn’t address acute hypotension urgency. Provider notification supersedes routine administration, as shock requires fluids and pressors now, not just infection control, to save the patient.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Antivirals like oseltamivir reduce influenza severity and duration by inhibiting viral replication. Administering them as prescribed is a key nursing action, supporting recovery and aligning with medical orders in interprofessional influenza care.

Choice B reason: Strict bedrest isn’t required for influenza; moderate activity aids recovery by preventing complications like pneumonia. Evidence favors rest as needed, not enforced immobility, making this less critical in a collaborative plan.

Choice C reason: Educating about annual vaccinations prevents future influenza via antibody production. It’s a proactive nursing role, enhancing patient autonomy and public health, integral to long-term interprofessional management strategies.

Choice D reason: Hydration and rest support immune function and symptom relief in influenza. Encouraging this replaces losses from fever, a fundamental nursing action enhancing recovery in collaboration with the healthcare team.

Choice E reason: Isolation via droplet precautions prevents influenza spread, a core nursing responsibility. It protects others, aligning with infection control protocols, making it essential in interprofessional care for a contagious patient.

A. Assess patient pain level associated with the chest tube. B. Check the water-seal chamber for the correct fluid level. C. Document the amount of drainage every 8 hours. D. Obtain samples of drainage for culture from the system.

Correct Answer is C

Explanation

Choice A reason: Assessing pain requires subjective interpretation and clinical judgment to gauge severity and response. This nursing task can’t be delegated, as assistants lack training to evaluate pain’s impact on respiratory status or intervention needs.

Choice B reason: Checking the water-seal chamber involves understanding pneumothorax mechanics and system integrity. This technical skill exceeds an assistant’s scope, requiring a nurse to ensure proper function and detect complications like air leaks.

Choice C reason: Documenting drainage volume is a routine task after RN measurement, involving recording observed data. It fits an assistant’s role, as it requires no analysis or intervention, making it a safe delegation for tracking output.

Choice D reason: Obtaining drainage samples involves sterile technique and system manipulation, risking infection or disruption. This skilled procedure remains a nursing duty, as assistants aren’t trained to handle invasive equipment safely.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2°F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student is learning about the interprofessional management of a patient diagnosed with influenza. Which of the following actions should the nursing student include in their care plan when collaborating with the healthcare team? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action could the nurse delegate to the assistive personnel (AP)?

Correct Answer is C

Explanation

Sara has been admitted to the unit for asthma exacerbation. Which assessment findings are commonly associated with asthma exacerbation? (Select all that apply)

Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

Complete the following sentence: Given the patient’s symptoms of dyspnea and fatigue, the nurse anticipates the primary care provider may increase the dose of (medication class) to help reduce fluid overload.

The nurse is assessing the patient’s medication list. Which of the following medications are commonly prescribed to manage symptoms of heart failure? (Select all that apply)

Propranolol (Inderal) is newly prescribed for a patient diagnosed with hypertension. Which information in the patient’s history would prompt the nurse to consult with the health care provider before giving this drug?

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?

When teaching the patient about preventing further episodes of pneumonia, the nurse should include which 5 topics?

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced nursing assistant?