A nurse is planning care for a client who has a new diagnosis of sepsis. Which of the following interventions is the nurse's priority?
Initiate oxygen therapy.
Administer antibiotics.
Obtain blood cultures.
Begin an IV crystalloid infusion.
The Correct Answer is A
A. Initiate oxygen therapy: Sepsis can lead to tissue hypoxia and organ dysfunction due to impaired perfusion. Oxygen therapy is the priority to ensure adequate oxygenation, prevent respiratory failure, and support vital organ function.
B. Administer antibiotics: Broad-spectrum antibiotics are essential to treat the underlying infection, but they should be given after obtaining blood cultures to ensure accurate pathogen identification and prevent delays in appropriate therapy.
C. Obtain blood cultures: Blood cultures must be collected before antibiotic administration to identify the causative organism, but stabilizing the client's oxygenation and perfusion takes precedence in acute management.
D. Begin an IV crystalloid infusion: Fluid resuscitation is crucial for managing septic shock, but oxygen therapy should be initiated first to immediately improve oxygen delivery and prevent hypoxia-related complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Insulin aspart and NPH insulin: Insulin aspart is a rapid-acting insulin, and NPH is an intermediate-acting insulin. These can be mixed in the same syringe to provide both immediate and prolonged glucose control, with aspart covering postprandial spikes and NPH maintaining basal levels.
B. Insulin degludec and NPH insulin: Insulin degludec is an ultra-long-acting insulin and should not be mixed with any other insulin, as mixing can alter its absorption and effectiveness.
C. Insulin glargine and insulin detemir: Both glargine and detemir are long-acting insulins and should not be mixed with any other insulin, as this can interfere with their mechanism of providing a steady release.
D. Insulin lispro and regular insulin: Insulin lispro is a rapid-acting insulin, and regular insulin is short-acting. These insulins should not be mixed because they have different onset and peak times, which can lead to unpredictable glucose control.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B,C"}}
Explanation
Sickle Cell Disease:
• Fatigue
Iron Deficiency Anemia:
• Ferritin level
• Fatigue
• Orthostatic hypotension
Pernicious Anemia:
• Vitamin B12 level
• Fatigue
Rationale:
• Vitamin B12 level: A decreased vitamin B12 level is characteristic of pernicious anemia, which results from impaired absorption of vitamin B12 due to intrinsic factor deficiency.
• Orthostatic hypotension: A drop in blood pressure upon standing is commonly seen in iron deficiency anemia due to reduced oxygen-carrying capacity and inadequate perfusion.
• Ferritin level: A low ferritin level indicates depleted iron stores, which is a hallmark of iron deficiency anemia.
• Fatigue: Fatigue is a common symptom in all three conditions due to reduced oxygen delivery to tissues. In sickle cell disease, fatigue results from chronic hemolysis and vaso-occlusive episodes. In iron deficiency anemia, it is caused by insufficient hemoglobin production. In pernicious anemia, fatigue results from ineffective erythropoiesis due to vitamin B12 deficiency.
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