The nurse is reviewing orders received for a client diagnosed with sepsis. Which order should the nurse question?
Administer oxygen via mask.
Obtain serum lactate level.
Infuse 0.9% NS at 50 mL/hr.
Obtain blood and urine cultures.
The Correct Answer is C
Choice A reason: Administering oxygen via mask is appropriate for a client with sepsis who may have compromised oxygenation.
Choice B reason: Obtaining a serum lactate level is important in sepsis as it can indicate the severity of the condition and guide treatment.
Choice C reason: An infusion rate of 0.9% Normal Saline at 50 mL/hr may be questioned because clients with sepsis may require more aggressive fluid resuscitation.
Choice D reason: Obtaining blood and urine cultures is essential before starting antibiotics to identify the causative organism in sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Impaired elimination may be a concern with pancreatitis due to potential complications affecting the gastrointestinal tract, but it is not the immediate priority.
Choice B reason: Fluid imbalance is the most critical issue in acute pancreatitis, as evidenced by inelastic skin turgor and concentrated urine, indicating dehydration, which can exacerbate the condition and lead to hypovolemic shock.
Choice C reason: Fever may be present due to inflammation or infection, but the temperature provided is not indicative of a significant fever and is not the priority over fluid imbalance.
Choice D reason: Nausea is a symptom of acute pancreatitis and while it needs to be managed, it is not the priority over fluid imbalance.
Correct Answer is D
Explanation
Choice A reason: Petechiae and bruising could be related to low platelet counts or clotting issues, but they are not directly indicated by the provided lab values.
Choice B reason: Jaundice and pruritus are symptoms associated with liver disease but are not specifically indicated by the lab values provided.
Choice C reason: Dyspnea and fatigue could be symptoms of many conditions, including liver disease, but they are not directly indicated by the lab values provided.
Choice D reason: Asterixis, a flapping tremor of the hands, and confusion are signs of hepatic encephalopathy, which can be associated with elevated serum ammonia levels, as indicated by the lab results.
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