A client admitted with possible sepsis. Which action will the nurse perform first.

Give an antipyretic.

Obtain ordered cultures.

Place the client in isolation.

Administer antibiotics.

Answer and Explanation

The Correct Answer is B

A. Give an antipyretic: Reducing fever can provide comfort but does not address the underlying infection. Treating symptoms is secondary to diagnostic confirmation.

B. Obtain ordered cultures: Obtaining blood, urine, or other cultures before starting antibiotics is essential for identifying the causative organism and guiding targeted therapy. This step should be performed first to ensure accurate diagnostic results.

C. Place the client in isolation: Isolation precautions are important to prevent spread of infection but are implemented concurrently with diagnostic and therapeutic interventions rather than as the first action.

D. Administer antibiotics: Antibiotics are crucial for sepsis management, but they should ideally be administered after cultures are obtained to avoid interfering with laboratory results.

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Free Nursing Study Resources

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

Explanation

A. Use normal saline to cleanse the skin around the pressure injury: Normal saline is nonirritating and promotes wound healing by gently cleansing without damaging tissue, making it best practice.

B. Soak eschar daily until it softens and can be removed: Routine soaking of stable eschar is not recommended, as eschar on heels or ischemic tissue may protect underlying tissue and should not be debrided unless ordered by a healthcare provider.

C. Conduct ongoing assessment that includes pain: Continuous evaluation of the wound, including pain assessment, helps guide care, detect complications, and optimize patient comfort.

D. Consult with a registered dietitian/nutritionist: Nutritional support is essential for wound healing, particularly protein and micronutrient intake, making collaboration with a dietitian best practice.

E. Consider the use of adjuvant therapies for nonhealing wounds: For chronic or nonhealing pressure injuries, advanced therapies like negative pressure wound therapy or growth factors may be indicated to promote healing.

F. Use antimicrobial agents to clean wounds that are affected: Routine use of topical antimicrobials is not recommended for all pressure injuries as it can delay healing and promote resistance; they are reserved for infected wounds.

A. Type and crossmatch for a blood transfusion. B. Increase the rate of IV Lactated Ringers solution per doctors order. C. Continue to monitor the laboratory results. D. Monitor Urine output every 8 hours.

Correct Answer is B

Explanation

A. Type and crossmatch for a blood transfusion: The elevated hemoglobin and hematocrit reflect hemoconcentration due to fluid loss from the burn, not blood loss requiring transfusion. Immediate transfusion is not indicated at this stage.

B. Increase the rate of IV Lactated Ringers solution per doctor's order: High hematocrit, hemoglobin, and sodium indicate significant fluid deficit and dehydration from burn-related plasma loss. Rapid fluid resuscitation with isotonic crystalloids like Lactated Ringers is necessary to restore circulating volume, maintain perfusion, and prevent shock.

C. Continue to monitor the laboratory results: Ongoing monitoring is important, but active intervention with fluid resuscitation is required immediately to address hypovolemia. Passive monitoring alone would delay critical treatment.

D. Monitor urine output every 8 hours: Frequent urine output monitoring is essential in burn patients, but the standard is usually every 1 hour during the initial resuscitation phase. Waiting 8 hours is inadequate to detect early signs of hypoperfusion or renal compromise.

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A client admitted with possible sepsis. Which action will the nurse perform first.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse cares for many clients with pressure injuries. What actions by the nurse are considered best practice? (Select all that applies)

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

Explanation

On admission to the burn unit, a client with an appropriate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 59%, Hgb 19.2 mg/dL, Serum K 5.0 mEq/L and serum Na 150 mEq/L. Which action will the nurse anticipate taking now?

Correct Answer is B

Explanation

After receiving change-of-shift report about the following four clients. Which client should the nurse assess first?

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