A 39-year-old client is admitted with a severely abscessed tooth. The nurse assess vital signs of BP 92/44, HR 134, RR 26, Spo2 90% on room air, temperature 38.9° C. What is the priority nursing intervention?

Administer prescribed antibiotics.

Obtain blood cultures and other labs.

Insert an indwelling urinary catheter.

Initiate intravenous fluid resuscitation.

Answer and Explanation

The Correct Answer is D

A. While antibiotics are essential to treat the infection, the client is showing signs of septic shock (hypotension, tachycardia, tachypnea, hypoxemia). Antibiotics alone will not immediately stabilize the patient’s circulatory compromise. Early fluid resuscitation takes priority to restore perfusion.

B. Blood cultures are necessary for guiding antibiotic therapy and identifying pathogens, but obtaining labs does not address the immediate hemodynamic instability. Delaying resuscitation while awaiting lab results can worsen organ perfusion.

C. Catheterization may be useful for monitoring urine output, which reflects perfusion, but it is not the first intervention. Immediate stabilization of blood pressure and circulation takes precedence.

D. The client’s low blood pressure (92/44), tachycardia (HR 134), tachypnea (RR 26), and hypoxemia (SpO2 90%) indicate septic shock with hypoperfusion. Rapid IV fluid administration (usually isotonic crystalloids) is the priority intervention to restore circulating volume, improve tissue perfusion, and prevent progression to multi-organ dysfunction.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

A. Acute kidney injury (AKI)is a common complication of electrical burns due to myoglobin release from muscle damage (rhabdomyolysis). Myoglobin can accumulate in the kidneys, causing renal tubular obstruction and acute tubular necrosis.

B. Dysrhythmiascan occur because electrical currents pass through the body and disrupt cardiac conduction, leading to arrhythmias, which may be life-threatening. Continuous cardiac monitoring is essential.

C. The iceberg effectrefers to the fact that electrical burns often cause deeper tissue injury than is visible on the skin, including muscle, nerve, and bone damage beneath the surface. This hidden injury can lead to complications such as compartment syndrome and rhabdomyolysis.

D. Hypernatremiais not a primary risk in electrical burns. Electrolyte imbalances are more commonly hyponatremia or hyperkalemia, especially during fluid shifts and muscle breakdown.

E. Bone fracturesmay occur if the patient experienced violent muscle contractions during the electrical shock. Electrical currents can cause severe tetanic muscle contractions, which can lead to fractures, especially in older adults with decreased bone density.

F. Fluid volume overloadis not typically a risk immediately after electrical burns. The initial concern is hypovolemia from fluid loss due to capillary leak and tissue injury, requiring aggressive fluid resuscitation. Overload may occur later if fluids are over-administered, but it is not an inherent risk of the burn itself.

A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system

Correct Answer is B

Explanation

A. Mediastinal chest tubes are specific for draining fluid or blood from the mediastinum after cardiac surgery, but the description in the question refers to the suction mechanism of the drainage system, not its anatomical placement.

B. A dry suction systemuses a mechanical suction monitor (bellow or dial)rather than a water column to regulate suction. It allows precise suction control, eliminates bubbling noises, and does not require water replenishment, preventing evaporation issues. This matches the description provided.

C. Wet suction systems use a water column to control suction. Bubbling in the water chamber regulates suction, and water can evaporate over time, which is different from the dry suction system described.

D. Dry-wet systems combine features of both dry and water-based suction systems, but the description specifies no water column is used to control suction, which aligns solely with the dry suction system.

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A 39-year-old client is admitted with a severely abscessed tooth. The nurse assess vital signs of BP 92/44, HR 134, RR 26, Spo2 90% on room air, temperature 38.9° C. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply:

Correct Answer is ["A","B","C","E"]

Explanation

Correct Answer is B

Explanation

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