A nurse is teaching a group of nurses about the sepsis resuscitation bundle. Which of the following instructions should the nurse include?
Hang a nitroprusside IV bolus infusion.
Check a client's troponin level.
Administer 30 mL/kg of 0.9% sodium chloride IV infusion.
Obtain a blood culture 30 min after administering an antibiotic.
The Correct Answer is C
Rationale:
A. Hang a nitroprusside IV bolus infusion: Nitroprusside is a potent vasodilator used primarily in hypertensive emergencies, not in early sepsis management. Vasodilation can worsen hypotension in septic patients, especially during the resuscitation phase.
B. Check a client's troponin level: Troponin is a cardiac biomarker used to evaluate myocardial injury, such as in acute coronary syndrome. It is not a standard part of the initial sepsis resuscitation bundle unless cardiac involvement is suspected.
C. Administer 30 mL/kg of 0.9% sodium chloride IV infusion: Rapid fluid resuscitation with crystalloids like normal saline is a core element of the sepsis bundle. It helps restore intravascular volume, maintain perfusion, and support blood pressure during the early management of sepsis and septic shock.
D. Obtain a blood culture 30 min after administering an antibiotic: Blood cultures should be obtained before administering antibiotics to accurately identify the causative organism. Giving antibiotics first may reduce the ability to isolate the pathogen, affecting targeted treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Hang a nitroprusside IV bolus infusion: Nitroprusside is a potent vasodilator used primarily in hypertensive emergencies, not in early sepsis management. Vasodilation can worsen hypotension in septic patients, especially during the resuscitation phase.
B. Check a client's troponin level: Troponin is a cardiac biomarker used to evaluate myocardial injury, such as in acute coronary syndrome. It is not a standard part of the initial sepsis resuscitation bundle unless cardiac involvement is suspected.
C. Administer 30 mL/kg of 0.9% sodium chloride IV infusion: Rapid fluid resuscitation with crystalloids like normal saline is a core element of the sepsis bundle. It helps restore intravascular volume, maintain perfusion, and support blood pressure during the early management of sepsis and septic shock.
D. Obtain a blood culture 30 min after administering an antibiotic: Blood cultures should be obtained before administering antibiotics to accurately identify the causative organism. Giving antibiotics first may reduce the ability to isolate the pathogen, affecting targeted treatment.
Correct Answer is B
Explanation
Rationale:
A. Health Insurance Portability and Accountability Act of 1996: HIPAA regulates the protection and confidentiality of patient health information. It does not address employee vaccination requirements or workplace safety related to infectious disease exposure.
B. Occupational Safety and Health Administration: OSHA requires employers to offer the hepatitis B vaccine to all employees who may be exposed to blood or other infectious materials. This is part of its Bloodborne Pathogens Standard to reduce occupational risk.
C. Professional standards review organization: These groups evaluate the quality and efficiency of care provided by healthcare institutions but are not regulatory bodies for workplace safety or immunization protocols.
D. Emergency Medical Treatment and Active Labor: EMTALA ensures public access to emergency services regardless of ability to pay. It is not related to employee vaccination or workplace infection control policies.
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