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

Administer an antipyretic.

Obtain specified cultures.

Administer antibiotics.

Place the client in isolation.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Administering an antipyretic would lower the client's fever, but it would not address the underlying cause of the sepsis. Antipyretics can mask important signs and symptoms of infection, making it more difficult to diagnose and treat the sepsis. It's important to identify the causative organism of sepsis to initiate appropriate antibiotic therapy.
Therefore, obtaining cultures to identify the causative organism is the priority action.
Choice B rationale:
Obtaining specified cultures is the most important action for a client with possible sepsis because it allows for the identification of the causative organism.
This information is essential for selecting the appropriate antibiotic therapy. Cultures should be obtained as soon as possible, before antibiotics are administered.
Choice C rationale:
While administering antibiotics is an important part of the treatment for sepsis, it is not the first action that the nurse should take.
Antibiotics should be administered after the causative organism has been identified.
Administering antibiotics before cultures are obtained can make it more difficult to identify the causative organism.
Choice D rationale:
Placing the client in isolation is important to prevent the spread of infection, but it is not the first action that the nurse should take.
The priority is to identify the causative organism and initiate appropriate treatment. The client can be placed in isolation after cultures have been obtained.

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Correct Answer is A

Explanation

Choice A rationale:

Assessing the patient's adherence to the drug regimen is the most crucial first step in this situation. Here's a comprehensive explanation:

1. Significance of Adherence in HIV Treatment:

Viral Suppression and Disease Progression: Adherence to antiretroviral therapy (ART) is paramount in HIV management. It directly impacts viral suppression, preventing disease progression, and reducing the risk of opportunistic infections and complications. Non-adherence can lead to viral rebound, increased viral load, and potential disease advancement.

Primary Cause of Treatment Failure: Suboptimal adherence is the leading cause of treatment failure in HIV patients. It can result in:

Reduced effectiveness of ART Development of drug resistance Increased healthcare costs Increased risk of transmission

2. Rationale for Prioritizing Adherence Assessment:

Direct Link to Viral Load and Health Status: A sudden decline in health status and a significant increase in viral load strongly suggest potential non-adherence. Assessing adherence early on can:

Identify the root cause of the clinical deterioration

Inform timely interventions to address adherence barriers Prevent further complications

3. Assessing Adherence Thoroughly:

Non-Judgmental Approach: Creating a supportive and non-judgmental environment is essential for honest and accurate assessment.

Open-Ended Questions: Utilize open-ended questions to explore potential challenges and barriers to adherence, such as: Difficulties with medication schedules

Side effects Financial constraints Forgetfulness

Mental health concerns Substance abuse

Lack of social support

Objective Measures: Complement patient reports with objective measures like:

Pill counts

Pharmacy refill records

Medication Event Monitoring Systems (MEMS)

4. Addressing Adherence Barriers:

Tailored Interventions: Based on the assessment findings, develop individualized strategies to enhance adherence, such as: Simplifying medication regimens

Addressing side effects

Providing medication reminders

Offering counseling and support services

Connecting patients with resources

5. Reassessing and Monitoring:

Continuous Evaluation: Regularly reassess adherence and viral load to ensure treatment effectiveness and make adjustments as needed.

Conclusion:

While other options (B, C, D) may provide valuable information, prioritizing adherence assessment is critical to promptly identify and address potential adherence issues, optimize treatment outcomes, and prevent further health decline in HIV patients experiencing viral rebound.

A. Let me inform you about the care you’ll receive post-surgery and the level of pain you can expect. B. If it’s any consolation, everyone feels nervous before surgery. C. Can you share with me what you’ve been informed about your surgery? D. I would be glad to explain the entire surgical procedure to you.

Correct Answer is C

Explanation

Choice A rationale:
While providing information about post-operative care and pain management is important, it may not directly address the patient's underlying anxiety or encourage them to express their concerns.
It could be perceived as dismissive of their feelings or as an attempt to control the conversation. It focuses on the future rather than the patient's present experience.
Choice B rationale:
This response, while intended to be reassuring, may minimize the patient's individual experience and feelings. It could make the patient feel as though their concerns are not being taken seriously.
It implies that anxiety is a normal and expected reaction, which may discourage the patient from sharing their specific worries.
Choice C rationale:
This response is open-ended and invites the patient to share their thoughts and feelings.
It demonstrates active listening and encourages the patient to take an active role in the conversation.
It allows the nurse to assess the patient's understanding of the surgery and to address any misconceptions or concerns. It conveys a sense of empathy and understanding, which can help to build trust and rapport with the patient.
Choice D rationale:
While offering to explain the procedure may be helpful, it may not be what the patient needs at the moment. It could overwhelm the patient with information, particularly if they are already feeling anxious.
It could shift the focus away from the patient's emotional needs and onto the technical aspects of the surgery.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with HIV-1 has experienced a sudden decline in health status accompanied by a significant increase in viral load. What is the first action the nurse should take?

Correct Answer is A

Explanation

A patient about to undergo surgery is expressing anxiety. Which nurse’s response is most likely to encourage further conversation with the patient?

Correct Answer is C

Explanation

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