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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Tachycardia and weight gain are not typically associated with low T4 levels. Tachycardia and weight loss are more commonly seen in hyperthyroidism, where T4 levels would be elevated.
Choice B reason: Diarrhea and hypoglycemia are not directly related to low T4 levels. Diarrhea can be a symptom of hyperthyroidism, while hypoglycemia is not commonly associated with thyroid function.
Choice C reason: Hypotension and periorbital edema are findings that can be associated with hypothyroidism, which is consistent with the low T4 level of 2.9 mcg/dL. Hypothyroidism can lead to reduced cardiac output and systemic vascular resistance, causing hypotension. Periorbital edema is also a common sign of hypothyroidism due to mucopolysaccharide deposition in the skin.
Choice D reason: Tremors and dyskinesias are more commonly associated with hyperthyroidism, not hypothyroidism. Elevated levels of thyroid hormones can lead to these neurological symptoms.
Correct Answer is C
Explanation
Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.
Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.
Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.
Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.
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