A 54-year-old male is 3 days postoperative following a colon resection. The nurse has delegated to the assistive personnel (AP) to obtain morning vital signs. At 8:00 AM, the AP reports that the client's oral temperature is 1018F.
Upon assessment, the nurse notes that the client is flushed and slightly diaphoretic. He appears lethargic, but responds to simple questions. His vital signs are now BP 92/42, HR 132, RR 28 and deep, and his temperature has risen to 102.6° F. Lungs are clear throughout. The surgical wound has a dressing that is moist with a moderate amount of purulent drainage.
Five minutes later, the nurse contacts the surgeon to report the abnormal findings, who prescribes:
A. Tylenol 650 mg PO prn q6h for a temperature above 101° F
B. Blood cultures x 2, taken 5 minutes apart
C. C&S of abdominal wound drainage
D. Vancomycin 750 mg IVPB over 1 hour every 24 hour
Over the next hour, the client continues to decline with a decreased level of consciousness and a temperature of 103.8° F. BP is 80/40, HR is 134, and RR is 34. The nurse calls the surgeon to report these findings and obtain orders for transfer to the ICU. When preparing for this transfer, the nurse notes that the client's O2 saturation is 87% on room air.
What is the priority nursing action?
Draw an arterial blood gas sample.
Apply oxygen at 2 to 3 L per nasal cannula.
Administer acetaminophen 650 mg by mouth.
Place the patient on a cardiac telemetry monitor.
The Correct Answer is B
A. While ABG analysis is important for evaluating oxygenation, ventilation, and acid-base status, it is diagnostic rather than therapeutic. Performing an ABG does not correct the low oxygen saturation or prevent further tissue hypoxia. Therefore, it is a secondary action after initiating oxygen.
B. Oxygen therapy directly addresses the immediate threat of hypoxemia, increasing oxygen delivery to vital organs and tissues. Prompt administration of supplemental oxygen is critical to prevent further deterioration of mental status, organ perfusion, and cardiac function. In a client with sepsis or septic shock, improving oxygenation is a top priority before or during transfer to a higher level of care like the ICU.
C. Treating fever is supportive care but does not resolve hypoxemia or hypotension, which are life-threatening. Fever management is important for comfort and infection control but is secondary to stabilizing oxygenation and perfusion.
D. Continuous cardiac monitoring is important for detecting arrhythmias associated with sepsis or hypoxemia, but it does not intervene in the immediate oxygen deficit. Monitoring alone cannot prevent organ dysfunction caused by low oxygen saturation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevated serum creatinine indicates impaired renal function, which is a sign of organ dysfunction. In cardiogenic shock, decreased cardiac output reduces perfusion to vital organs, and rising creatinine is an early indicator of kidney involvementin MODS. This finding reflects multi-organ compromiserather than isolated symptoms.
B. Chest pressure reflects ongoing myocardial ischemia, which is the underlying cause of cardiogenic shock, but it does not indicate that other organs are failing.
C. Wheezing may indicate pulmonary congestion or fluid overload, but it is not specific for MODS. It reflects one organ systemrather than multi-organ dysfunction.
D. Cool extremities and weak pulses indicate poor perfusion and peripheral vasoconstriction, common in shock. While concerning, these are signs of inadequate circulationrather than definitive evidence of multiple organ failure.
Correct Answer is A
Explanation
A. Neurogenic shockis correct because it occurs following a spinal cord injury, especially above T6, leading to loss of sympathetic nervous system tone. This results in hypotension, bradycardia, and warm, dry skindue to unopposed parasympathetic activityand peripheral vasodilation. The combination of low blood pressure, low heart rate, and warm skin is classic for neurogenic shock, distinguishing it from other types of shock.
B. Anaphylactic shockis incorrect because it usually presents with hypotension, tachycardia, and warm, flushed skin, often accompanied by urticaria, airway swelling, and respiratory distress, which are not described in this client.
C. Septic shockis incorrect because septic shock typically presents with hypotension, tachycardia, fever or hypothermia, and warm, flushed skin in the early stages. This client’s heart rate is bradycardic, not tachycardic, and he has a normal temperature, making sepsis less likely.
D. Hypovolemic shockis incorrect because it usually presents with hypotension, tachycardia, and cool, clammy skindue to decreased circulating volume and sympathetic compensatory mechanisms. This client’s skin is warm and dry, which is inconsistent with hypovolemic shock.
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