A nurse is caring for a 73-year-old client in the emergency department (ED).
It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.
Insert a nasogastric (NG) tube.
Measure lactate level.
Obtain a wound culture.
Administer broad-spectrum antibiotics.
Obtain blood cultures.
Type and cross-match for 2 units of packed RBCs.
Rapidly administer 30 mL/kg of normal saline.
Obtain a urine specimen.
Correct Answer : B,D,E,G
A. Inserting a nasogastric (NG) tube is not a priority action in the initial management of sepsis.
B. Measuring lactate levels is a priority action in the initial management of sepsis. Elevated lactate levels indicate tissue hypoxia and are associated with increased mortality in septic patients.
C. Obtaining a wound culture is not a priority action in the initial management of sepsis.
D. Administering broad-spectrum antibiotics is a priority action in the initial management of sepsis. Prompt antibiotic therapy is associated with improved outcomes in septic patients.
E. Obtaining blood cultures is a priority action in the initial management of sepsis. Blood cultures help identify the causative organism and guide antibiotic therapy.
F. Type and cross-matching for packed RBCs is not a priority action in the initial management of sepsis.
G. Rapidly administering 30 mL/kg of normal saline is a priority action in the initial management of sepsis. This bolus of fluid helps restore tissue perfusion and hemodynamic stability.
H. Obtaining a urine specimen is not a priority action in the initial management of sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Aphasia, or difficulty with language comprehension and expression, is more commonly associated with left hemisphere strokes.
B. Inability to recognize family members is a possible manifestation of right hemisphere stroke, particularly if the stroke affects the right parietal lobe. This condition is called prosopagnosia.
C. Right hemiparesis, or weakness on the right side of the body, is a possible manifestation of left hemisphere stroke, not right hemisphere stroke.
D. Difficulty reading is more commonly associated with left hemisphere strokes, which affect language centers involved in reading.
Correct Answer is D
Explanation
A. Rubbing hands and arms to dry is not a step in the hand hygiene process. After washing, the hands should be dried thoroughly with a clean towel or air dryer.
B. Adjusting the water temperature to feel hot is not necessary for effective hand hygiene. The water should be warm, but not hot, to avoid skin damage.
C. Holding the hands higher than the elbows is not a step in the hand hygiene process.
D. Applying 4 to 5 mL of liquid soap to the hands is the correct amount of soap to use for effective hand hygiene. The soap should be rubbed onto the hands and wrists for at least 20 seconds before rinsing thoroughly with water.
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