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A nurse is caring for a 73-year-old male client in the emergency department (ED).

Exhibits

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.

Obtain a wound culture

Rapidly administer 30 mL/kg of normal saline

Insert a nasogastric (NG) tube

Obtain blood cultures

Administer broad-spectrum antibiotics

Measure lactate level

Type and cross-match for 2 units of packed RBCs

Obtain a urine specimen

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale:

Obtaining a wound culture is crucial to identify the causative organism and guide appropriate antibiotic therapy. Prompt identification and treatment of the infection source can prevent further systemic complications.

Choice B rationale:

Rapidly administering 30 mL/kg of normal saline helps to restore intravascular volume, improve hemodynamic stability, and enhance tissue perfusion. This intervention is vital in the initial management of sepsis to prevent organ dysfunction.

Choice D rationale:

Obtaining blood cultures before initiating antibiotic therapy is essential to identify the causative microorganism and tailor antibiotic treatment. This step ensures accurate diagnosis and effective management of sepsis.

Choice E rationale:

Administering broad-spectrum antibiotics as soon as possible is critical in managing sepsis. Early and appropriate antibiotic therapy significantly reduces mortality and morbidity by targeting the suspected pathogens promptly.

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Correct Answer is C

Explanation

Choice A rationale

Bubbling in the water seal chamber with exhalation indicates that air is still being removed from the pleural space, which is expected with a pneumothorax and is not a cause for immediate concern.

Choice B rationale

Eyelets not being visible indicate that the chest tube is properly placed within the pleural space, not an urgent issue.

Choice C rationale

Movement of the trachea towards the unaffected side is a sign of tension pneumothorax, which requires immediate intervention as it can compromise respiratory function.

Choice D rationale

Crepitus in the area above and surrounding the insertion site indicates subcutaneous emphysema, which can occur but does not necessitate immediate provider notification unless severe.

A. Obtain an influenza vaccine annually. B. Inject insulin in the deltoid muscle. C. Administer glucagon for hyperglycemia. D. Take glyburide with breakfast.

Correct Answer is A

Explanation

Choice A rationale

Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes to reduce the risk of infections that can exacerbate their condition.

Choice B rationale

Injecting insulin in the deltoid muscle is not standard practice as subcutaneous tissue in the abdomen or thigh is preferred for insulin absorption.

Choice C rationale

Administering glucagon is for hypoglycemia, not hyperglycemia; insulin or other medications manage hyperglycemia.

Choice D rationale

Taking glyburide is not suitable for type 1 diabetes as it requires insulin management. .

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A nurse is caring for a 73-year-old male client in the emergency department (ED). Exhibits 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.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a pneumothorax with a chest tube in place.For which of the following findings should the nurse notify the provider?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a 73-year-old male client in the emergency department (ED). Exhibits 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.

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A nurse is caring for a 73-year-old male client in the emergency department (ED).

Exhibits

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.