You’re providing care to four patients.

Select all the patients who are at risk for developing sepsis:

A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

A 78-year-old female with diabetes mellitus who is recovering from colon surgery.

A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place.

A 55-year-old male who is a recent kidney transplant recipient.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale
A 65-year-old male recovering from right lobectomy for treatment of lung cancer is at risk for developing sepsis. Post-surgical patients, especially those with cancer, are at increased risk due to potential infection at the surgical site and a weakened immune system from the cancer and/or its treatment.
Choice B rationale
A 78-year-old female with diabetes mellitus who is recovering from colon surgery is at risk for developing sepsis. Diabetes can impair the immune system, making it harder for the body to fight off infections. Additionally, any surgical procedure carries a risk of infection.
Choice C rationale
A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place is at risk for developing sepsis. Hospitalized patients, particularly those with invasive devices like catheters and central lines, are at increased risk due to potential introduction of bacteria into the body.
Choice D rationale
A 55-year-old male who is a recent kidney transplant recipient is at risk for developing sepsis. Transplant recipients are often on immunosuppressive therapy to prevent organ rejection, which can leave them more susceptible to infections.

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Correct Answer is ["B","D"]

Explanation

Choice A rationale
The need for Metoprolol (Lopresor) STAT does not necessarily indicate progression to septic shock. Metoprolol is a beta-blocker used to treat high blood pressure, heart failure, and angina. While it may be used in the management of sepsis to control heart rate, its use does not specifically indicate progression to septic shock.
Choice B rationale
The need for Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement is a strong indicator of septic shock. Norepinephrine is a vasopressor, a type of medication used to increase blood pressure. In septic shock, vasopressors are often required to maintain adequate blood pressure and organ perfusion despite aggressive fluid resuscitation.
Choice C rationale
A serum lactate level less than 2 mmol/L is generally not indicative of septic shock. Elevated lactate levels can indicate tissue hypoperfusion, a condition that may occur in septic shock. However, a level less than 2 mmol/L is typically considered within the normal range.
Choice D rationale
A blood pressure of 70/34 after the fluid bolus could indicate progression to septic shock. In septic shock, despite aggressive fluid resuscitation, blood pressure often remains dangerously low, which can lead to inadequate blood flow to the organs.

A. Newly admitted patient with a BP of 150/87 mm Hg. B. Patient with left ventricular failure who has a BP of 110/70 mm Hg. C. Postoperative patient with a BP of 116/42 mm Hg. D. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.

Correct Answer is C

Explanation

The patient with a blood pressure of 116/42 mm Hg has a mean arterial pressure (MAP) of approximately 67 mm Hg, which is less than the standard policy of 70 mm Hg. This could indicate inadequate blood flow to the vital organs, necessitating notification of the healthcare provider.

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You’re providing care to four patients. Select all the patients who are at risk for developing sepsis:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D"]

Explanation

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

Correct Answer is C

Explanation

A patient has been admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI). The patient is restless, anxious, has a blood pressure of 86/40 mm Hg, and a heart rate of 132 beats/min. What is the priority problem for this patient?

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The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?

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A 75-year-old male experiences severe chest pain and calls 911. Given that lab findings indicate elevated levels of cardiac troponins I and T, what condition does the nurse suspect?

A patient with severe pericarditis has developed a large pericardial effusion and is symptomatic. What type of procedure should the physician order to help treat this condition?

You’re providing care to four patients.

Select all the patients who are at risk for developing sepsis: