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.

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Correct Answer is ["B","C","E","F","G"]

Explanation

Choice A reason: Staying indoors may limit exposure but isn’t practical or evidence-based for pneumonia prevention. It’s less effective than vaccines or hygiene, as pathogens persist indoors, reducing its priority in teaching.

Choice B reason: Yearly flu vaccine prevents influenza, a pneumonia risk factor, by inducing immunity. It’s a cornerstone of prevention, reducing respiratory infections that predispose to bacterial pneumonia, per public health guidelines.

Choice C reason: Regular exercise and nutrition boost immunity, reducing pneumonia risk. Strong lungs and host defenses limit infection severity, making this a key lifestyle topic for long-term respiratory health protection.

Choice D reason: Using a fan circulates air but doesn’t prevent pneumonia pathogens effectively. It may dry mucosa, increasing susceptibility, so it’s not a standard recommendation compared to vaccines or hygiene.

Choice E reason: Staying away from crowds reduces exposure to respiratory pathogens causing pneumonia. It’s practical during outbreaks, complementing vaccines and hygiene as a behavioral strategy to lower infection risk.

Choice F reason: Handwashing removes pathogens, preventing pneumonia transmission via contact. It’s a simple, evidence-based habit, critical in breaking infection chains, making it essential in patient education for prevention.

Choice G reason: Pneumonia vaccine (e.g., PCV13, PPSV23) protects against Streptococcus pneumoniae, a top cause. It’s a primary prevention tool, reducing incidence, strongly recommended for at-risk patients in teaching plans.

A. Ask the healthcare provider about prescribing Streptomycin. B. Discuss injectable antibiotics with the health care provider. C. Teach about drug-resistant TB. D. Ask the patient whether medications were taken as directed.

Correct Answer is D

Explanation

Choice A reason: Streptomycin treats TB, but persistent AFB after 2 months suggests resistance or non-adherence. Requesting it now skips assessing compliance, which is critical first, as adding drugs prematurely may worsen resistance.

Choice B reason: Injectable antibiotics (e.g., amikacin) address resistant TB, but without confirming adherence, this is premature. Non-compliance is common; discussing this assumes resistance without evidence, delaying root cause investigation.

Choice C reason: Teaching about drug-resistant TB is relevant if resistance is confirmed, not assumed. Positive AFB may reflect non-adherence, so education is secondary to verifying medication use, which drives next steps.

Choice D reason: Asking about adherence checks if the patient took drugs as directed, a common reason for persistent AFB. Non-compliance delays sputum conversion, making this the first action to guide further treatment decisions.

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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

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

Correct Answer is ["B","C","E","F","G"]

Explanation

After 2 months of prescribed treatment with isoniazid, rifampin, pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action would the nurse take next?

Correct Answer is D

Explanation

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