A nurse is caring for a client who developed a wound infection. Despite aggressive fluid resuscitation, the client has a blood pressure of 78/50 mm Hg and a heart rate of 136 beats per minute. The nurse contacts the provider. Which of the following orders does the nurse expect to receive from the provider?
Start intravenous norepinephrine 0.1 mcg/kg/min
Administer intravenous vancomycin 1 g every 12 hours
Administer intravenous furosemide 40 mg
Start intravenous dopamine 5 mcg/kg/min
The Correct Answer is A
Choice A reason: Norepinephrine is a vasopressor used to treat septic shock from a wound infection, which causes vasodilation and hypotension. By stimulating alpha-adrenergic receptors, it increases vascular tone, raising blood pressure to improve tissue perfusion. The client’s severe hypotension (78/50 mm Hg) and tachycardia (136 bpm) indicate shock, making norepinephrine an appropriate choice to stabilize hemodynamics.
Choice B reason: Vancomycin treats infections like those caused by methicillin-resistant Staphylococcus aureus, common in wound infections. However, it does not address the client’s immediate hypotension and tachycardia, which indicate septic shock. Antibiotics are crucial for infection source control but do not rapidly correct hemodynamic instability, so this is not the primary order expected now.
Choice C reason: Furosemide, a diuretic, promotes urine output and is used in fluid overload conditions like heart failure. In septic shock with hypotension (78/50 mm Hg), it would worsen hypovolemia by reducing intravascular volume, further decreasing blood pressure and perfusion. This is contraindicated in this scenario, as fluid retention is not the primary issue.
Choice D reason: Dopamine, at 5 mcg/kg/min, primarily enhances cardiac output and renal perfusion but has less potent vasopressor effects than norepinephrine. In septic shock with profound hypotension, norepinephrine is preferred for its stronger vasoconstrictive action to restore blood pressure. Dopamine may be used but is less effective for this client’s severe hemodynamic instability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Frequent skin assessments allow early detection of pressure injury signs, such as non-blanchable redness or skin breakdown. By identifying at-risk areas like the sacrum or heels, nurses can implement preventive measures promptly. This reduces tissue ischemia from prolonged pressure, preventing progression to ulcers by ensuring timely intervention to protect skin integrity.
Choice B reason: Frequent turning and positioning relieve pressure on bony prominences, reducing ischemia and tissue damage. Repositioning every 2 hours promotes blood flow, preventing prolonged compression of capillaries, which leads to hypoxia and necrosis. This is a cornerstone of pressure injury prevention, especially in immobile patients with limited tissue perfusion.
Choice C reason: Optimizing nutrition ensures adequate protein and micronutrient intake, essential for tissue repair and maintenance. Malnutrition impairs collagen synthesis and immune function, increasing susceptibility to skin breakdown. Adequate caloric and protein intake supports skin integrity, reducing the risk of pressure injuries by enhancing tissue resilience and healing capacity.
Choice D reason: Maintaining the head of the bed at a 45-degree angle increases shear forces on the sacrum and coccyx, potentially exacerbating pressure injury risk. While it may aid respiratory function, it does not directly prevent pressure injuries and may contribute to skin breakdown in immobile patients due to increased frictional forces.
Choice E reason: Inspecting the sacrum for blanching is part of skin assessment but is not an intervention to reduce incidence. Blanching indicates intact capillary perfusion, but non-blanchable redness signals early damage. While useful for staging, it is a diagnostic step, not a preventive measure like repositioning or nutrition, which actively reduce pressure injury risk.
Correct Answer is A
Explanation
Choice A reason: A clear liquid diet the day before a colonoscopy ensures the bowel is free of solid residue, allowing clear visualization of the colon mucosa. Clear liquids like broth, juice, or water do not leave particulate matter, facilitating effective bowel cleansing with laxatives, critical for accurate detection of polyps or abnormalities during the procedure.
Choice B reason: Taking antibiotics the morning of a colonoscopy is not standard practice. Antibiotics are not routinely required for bowel preparation, as the procedure carries a low infection risk. They may be used in specific cases, like patients with heart valve conditions, but this is not a general instruction for colonoscopy preparation.
Choice C reason: Drinking milk is contraindicated during colonoscopy preparation. Milk is not a clear liquid and leaves residue in the bowel, obstructing visualization during the procedure. A clear liquid diet is required to ensure the colon is clean, as dairy products can interfere with effective bowel cleansing and diagnostic accuracy.
Choice D reason: Avoiding water during bowel prep is incorrect. Adequate hydration is essential during colonoscopy preparation to prevent dehydration from laxative-induced fluid loss. Drinking water supports bowel cleansing and maintains electrolyte balance, ensuring patient safety and comfort during the prep process and the procedure itself.
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