Which of the following interventions is considered a priority when treating a patient who presents with septic shock?
obtaining wound and blood
removing or controlling potentially infected sources
initiation of an intravenous line and fluid
drawing blood for hematology and chemistry studies
The Correct Answer is C
Septic shock is a life-threatening condition characterized by severe infection, systemic inflammation, and inadequate tissue perfusion. In this critical situation, one of the initial priorities is to restore intravascular volume and improve tissue perfusion. Initiation of an intravenous line allows for the administration of fluids and other necessary medications to support the patient's hemodynamic stability.
While the other interventions mentioned are also important components of septic shock management, the immediate priority is to address hypotension and tissue hypoperfusion through fluid resuscitation:
A. Obtaining wound and blood cultures in (option A) is incorrect because: Cultures are important to identify the source and causative organisms of the infection. However, fluid resuscitation should take priority over obtaining cultures, as it is necessary to stabilize the patient's hemodynamics.
B. Removing or controlling potentially infected sources in (option B) is incorrect because: Identifying and controlling the source of infection is crucial in septic shock management to prevent further progression. However, initiating fluid resuscitation is more time-sensitive and should be prioritized.
D. Drawing blood for hematology and chemistry studies in (option D) is incorrect because Laboratory studies are important for evaluating organ function and guiding treatment. However, the immediate focus should be on fluid resuscitation to address the underlying hypoperfusion and stabilize the patient's condition.
Therefore, the intervention considered a priority when treating a patient who presents with septic shock is the initiation of an intravenous line and fluid administration to restore intravascular volume and improve tissue perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In a patient receiving mechanical ventilation, a high respiratory rate can indicate increased work of breathing and potential airway obstruction. COPD patients, in particular, may have excessive mucus production and airway inflammation, leading to mucus plugging and compromised airway clearance. Suctioning may be necessary to remove excessive secretions and maintain a patent airway.
A. The pulse oximeter shows a SpO2 of 90% in (option A) is incorrect because While a SpO2 of 90% is suboptimal and may require intervention, it does not specifically indicate the need for suctioning. Other interventions, such as adjusting oxygen delivery or ventilation settings, may be more appropriate.
B. The patient has not been suctioned for the last 6 hours in (option B) is incorrect because The duration since the last suctioning episode alone does not necessarily indicate the need for suctioning. The need for suctioning should be based on the patient's clinical presentation, such as signs of airway obstruction or excessive secretions.
D. The lungs have occasional audible expiratory wheezes in (option D) which is incorrect because Occasional audible expiratory wheezes may be common in patients with COPD and may not specifically indicate the need for suctioning. Wheezing is more commonly associated with narrowing of the airways, and suctioning is typically performed to clear secretions or maintain airway patency.
C. Therefore, in a COPD patient receiving mechanical ventilation, a high respiratory rate (C) is the assessment information that would indicate the need for suctioning to help remove excessive secretions and ensure a patent airway
Correct Answer is B
Explanation
Systemic vascular resistance represents the resistance to blood flow in the systemic circulation. It is an important indicator of afterload, which is the force against which the left ventricle must pump to eject blood into the systemic circulation. By monitoring the changes in SVR, the nurse can assess the impact of medications aimed at reducing left ventricular afterload.
A. Pulmonary artery wedge pressure (PAWP) in (option A) is incorrect because: PAWP is a measure of left ventricular preload and reflects the pressure within the left atrium and left ventricle at end-diastole. It is not specifically related to afterload reduction.
C. Pulmonary vascular resistance (PVR) in (option C) is incorrect because: PVR represents the resistance to blood flow in the pulmonary circulation. It is not directly related to left ventricular afterload.
D. Central venous pressure (CVP) in (option D) is incorrect because: CVP reflects the pressure in the right atrium and is an indicator of right-sided cardiac function. It is not specifically related to left ventricular afterload reduction.
Therefore, to assess the effectiveness of medications in reducing left ventricular afterload, the nurse should monitor the systemic vascular resistance (SVR).
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