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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Blood pressure 108/62 mm Hg: Lisinopril is an antihypertensive, and a systolic BP above 90 mm Hg is typically not considered an adverse effect. Hypotension can occur but is more concerning if it results in symptoms such as dizziness or syncope.

B. Potassium 3.5 mEq/L (3.5 to 5 mEq/L): Lisinopril can cause hyperkalemia, but a potassium level of 3.5 mEq/L is within the normal range. Monitoring potassium levels is essential, but this finding does not indicate an adverse effect.

C. Frequent, nonproductive cough: A dry, persistent cough is a common adverse effect of lisinopril due to the accumulation of bradykinin. It often does not resolve until the medication is discontinued or switched to an alternative, such as an angiotensin receptor blocker (ARB).

D. Frequent, painless urination: Lisinopril does not typically cause increased urination. While it affects renal function, it is more likely to lead to hyperkalemia or reduced glomerular filtration rate in susceptible individuals.

A. "The surgeon will make a small incision in your abdomen." B. "You may experience referred shoulder pain." C. "Your procedure will be scheduled during menstruation." D. "Warm saline will be instilled via the cervix."

Correct Answer is B

Explanation

A. "The surgeon will make a small incision in your abdomen.": A hysterosalpingography is a fluoroscopic imaging procedure that does not require surgical incisions. Contrast dye is injected through the cervix to visualize the uterus and fallopian tubes.

B. "You may experience referred shoulder pain.": Referred shoulder pain is a common side effect due to peritoneal irritation caused by the contrast dye if it spills into the peritoneal cavity, particularly when the fallopian tubes are patent. This discomfort is temporary and resolves on its own.

C. "Your procedure will be scheduled during menstruation.": The test is typically scheduled after menstruation but before ovulation (days 7-10 of the cycle) to ensure the uterus is clear of blood and to avoid disrupting an early pregnancy.

D. "Warm saline will be instilled via the cervix.": Hysterosalpingography uses iodine-based contrast dye for X-ray imaging, not warm saline. Saline infusion is used in sonohysterography, which is an ultrasound-based procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking lisinopril. Which of the following findings should the nurse document in the client's medical record as an adverse effect?

Correct Answer is C

Explanation

A nurse is providing teaching to a client about an upcoming hysterosalpingography. Which of the following statements should the nurse include?

Correct Answer is B

Explanation

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