A nurse is caring for a client with septic shock. The client’s blood pressure is 80/50 mm Hg, and lactate levels are elevated. Which intervention is the nurse’s priority?

Administer IV antibiotics

Initiate vasopressor therapy

Obtain blood cultures

Administer IV corticosteroids

Answer and Explanation

The Correct Answer is B

Choice A reason: IV antibiotics are critical in septic shock to treat the underlying infection, but they take hours to act. Hypotension (80/50 mm Hg) and elevated lactate indicate tissue hypoperfusion, requiring immediate restoration of blood pressure. Vasopressors address shock more rapidly, making antibiotics secondary in the acute stabilization phase.

Choice B reason: Septic shock with blood pressure of 80/50 mm Hg and elevated lactate indicates severe hypoperfusion and tissue hypoxia. Vasopressor therapy, like norepinephrine, restores blood pressure, improving organ perfusion. The ABCDE approach prioritizes circulation, making vasopressors the immediate intervention to prevent organ failure and death in this critical condition.

Choice C reason: Obtaining blood cultures identifies the causative organism in septic shock, guiding antibiotic therapy. However, it does not address immediate hypotension and hypoperfusion, indicated by low blood pressure and high lactate. Vasopressors stabilize circulation first, making cultures a secondary step in the acute management of septic shock.

Choice D reason: IV corticosteroids may be used in refractory septic shock to support adrenal function, but they are not the first-line intervention. Hypotension and elevated lactate require immediate vasopressor therapy to restore perfusion. Corticosteroids are adjunctive and slower-acting, making them less critical than vasopressors in the initial stabilization of septic shock.

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Correct Answer is A

Explanation

Choice A reason: Deep partial- and full-thickness burns to the neck and chest risk airway edema due to thermal injury, leading to obstruction. The resuscitation phase prioritizes the ABCDE approach, with airway as the first concern. Ensuring a patent airway via assessment or intubation prevents respiratory arrest, making this the most critical intervention.

Choice B reason: Pain medication is essential for burn patients due to severe pain from nerve exposure, but it is not the priority in the resuscitation phase. The ABCDE approach places airway and breathing above pain management. Airway compromise from neck burns can be fatal, making pain control secondary to airway patency.

Choice C reason: Inserting an indwelling urinary catheter monitors urine output, critical for assessing fluid resuscitation in burns. However, in the ABCDE approach, airway takes precedence over circulation monitoring. Neck and chest burns risk rapid airway obstruction, making catheter insertion a secondary intervention after ensuring airway and breathing are stable.

Choice D reason: Fluid resuscitation is vital in burns to correct hypovolemia from plasma leakage, but it follows airway and breathing in the ABCDE approach. Neck and chest burns pose an immediate airway threat due to edema, requiring prioritization of airway patency to prevent respiratory failure before addressing circulatory needs.

A. Hypercapnia with respiratory alkalosis B. Pulmonary hypertension C. Severe hypoxemia despite supplemental oxygen D. Pleural effusion

Correct Answer is C

Explanation

Choice A reason: Hypercapnia with respiratory alkalosis is not typical in ARDS. ARDS primarily causes severe hypoxemia due to alveolar damage and impaired gas exchange. Hypercapnia (elevated CO2) may occur in advanced respiratory failure, but respiratory alkalosis is more associated with hyperventilation in early stress responses, not ARDS’s hallmark of refractory hypoxemia.

Choice B reason: Pulmonary hypertension can develop in ARDS due to hypoxic vasoconstriction and vascular remodeling from inflammation, but it is not the primary or most common symptom. ARDS is characterized by diffuse alveolar damage leading to severe hypoxemia, with pulmonary hypertension being a secondary complication rather than the defining clinical feature.

Choice C reason: Severe hypoxemia despite supplemental oxygen is the hallmark of ARDS. It results from alveolar flooding, surfactant loss, and ventilation-perfusion mismatch, impairing oxygen diffusion. Even high-flow oxygen fails to correct low PaO2 due to shunting and non-functional alveoli, making this the most common and critical symptom requiring urgent intervention.

Choice D reason: Pleural effusion is not a primary feature of ARDS. It may occur in conditions like heart failure or infection but is less common in ARDS, which primarily involves alveolar edema and inflammation. The dominant clinical issue in ARDS is severe hypoxemia due to impaired gas exchange, not fluid accumulation in the pleural space.

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A nurse is caring for a client with septic shock. The client’s blood pressure is 80/50 mm Hg, and lactate levels are elevated. Which intervention is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his neck, chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?

Correct Answer is A

Explanation

Which of the following is a clinical symptom most commonly associated with Acute Respiratory Distress Syndrome (ARDS)?

Correct Answer is C

Explanation

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

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