A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?

Reference Range:

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Administer famotidine 20 mg IV.

Raise oxygen by 10 percent.

Increase dopamine 2 mcg/kg.

Titrate insulin infusion by 1 unit/hour.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Administer famotidine 20 mg IV: Famotidine is used for stress ulcer prophylaxis in critically ill clients but does not address the current protocol-driven abnormalities. The client’s immediate issues relate to glucose control, hemodynamics, and oxygenation.

B. Raise oxygen by 10 percent: The client’s oxygen saturation is 92% on 50% oxygen, which is acceptable in the setting of critical illness and MODS. There is no evidence of acute hypoxemia requiring escalation at this time. Oxygen therapy adjustments are not prioritized when saturation goals are being met.

C. Increase dopamine 2 mcg/kg/min: Dopamine is being titrated to maintain a MAP greater than 65 mm Hg, and the current MAP is 66 mm Hg, meeting the target. Increasing dopamine could unnecessarily raise heart rate and myocardial oxygen demand. No titration is indicated while the hemodynamic goal is achieved.

D. Titrate insulin infusion by 1 unit/hour: The blood glucose level of 160 mg/dL falls within the 150–199 mg/dL range, which requires an increase in insulin infusion by 1 unit/hour per protocol. Adjusting the insulin drip maintains tight glycemic control, which is essential in MODS to reduce infection risk and improve outcomes.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Rationale:
A. Call the chaplain to encourage the wife to wait outside of the room: While spiritual support is valuable, involving a chaplain does not immediately address the safety and efficiency needs during a life-threatening emergency. Immediate communication with the family is more effective in this situation.

B. Explain that the healthcare team needs space to treat her husband: Clear, calm, and direct communication informs the family member of the critical need for room access and safety during resuscitation. This approach prioritizes patient care while showing respect and empathy for the spouse’s emotions, helping her understand the necessity of leaving temporarily.

C. Ask an administrative supervisor to assist the wife to the waiting area: Involving administration may escalate tension and delay urgent care. While sometimes necessary for compliance issues, this is not the first-line approach during an acute resuscitation.

D. Allow the wife to stay at the bedside with a healthcare team member: Allowing family presence can be supportive in some situations, but during active VF resuscitation, space and immediate access to the patient are critical. Safety and efficiency of the resuscitation take priority.

A. Give a 0.9% normal saline bolus. B. Collect specimens for blood cultures. C. Obtain blood for serum glucose. D. Infuse first dose of antibiotics

Correct Answer is B

Explanation

Rationale:
A. Give a 0.9% normal saline bolus: Fluid resuscitation is a key component of sepsis management to support perfusion and blood pressure. However, initiating fluids does not take precedence over obtaining diagnostic cultures when the client is hemodynamically stable. Identifying the causative organism guides targeted therapy.

B. Collect specimens for blood cultures: Blood cultures must be obtained before initiating antibiotic therapy to accurately identify the infectious organism. A markedly elevated WBC count supports severe infection, and early culture collection improves diagnostic accuracy. This step is time-sensitive and directly impacts the effectiveness of subsequent antibiotic treatment.

C. Obtain blood for serum glucose: Serum glucose monitoring is important in sepsis due to stress-induced hyperglycemia. However, it does not influence immediate antimicrobial decision-making. This assessment can be performed after critical diagnostic specimens are collected.

D. Infuse first dose of antibiotics: Early antibiotics are essential in sepsis management, but administering them before obtaining blood cultures can compromise the ability to identify the pathogen. Best practice is to collect cultures first, then promptly start antimicrobial therapy.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The rapid response team transfers a client with sepsis to the intensive care unit (ICU). The client's white blood cell count is 28,000/mm3 (28 x 10^9/L). Which intervention should the nurse implement first? Reference Range: White blood cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 10^9/L)]

Correct Answer is B

Explanation

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