A patient has been diagnosed with septic shock.
What collaborative interventions would be expected? (Select all that apply)
Temperature control for either hypothermia or hyperthermia.
Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine.
Administration of a thrombolytic (streptokinase).
Subcutaneous administration of epinephrine (1:1000) 0.5 to 1 ml every 5 to 15 minutes.
Blood cultures from all suspected sources before administration of antibiotics.
Vigorous intravenous fluid resuscitation with 0.9% sodium chloride.
Correct Answer : A,B,E,F
Choice A rationale:
Temperature control for either hypothermia or hyperthermia is crucial in septic shock management. Here's a detailed explanation:
Hypothermia:
Mechanism: Septic shock often causes impaired thermoregulation, leading to hypothermia. It can worsen shock by decreasing cardiac output, impairing coagulation, and promoting vasoconstriction.
Intervention: Active warming measures are essential, including: External warming devices (e.g., blankets, forced air warmers) Intravenous fluids warmed to 39-42°C
Warmed humidified oxygen
Minimizing exposure and covering the patient Hyperthermia:
Mechanism: Sepsis can trigger an excessive inflammatory response, leading to hyperthermia. It can exacerbate tissue injury, increase metabolic demands, and worsen organ dysfunction.
Intervention: Aggressive measures to lower temperature are necessary, including:
Antipyretic medications (e.g., acetaminophen, ibuprofen) External cooling methods (e.g., cooling blankets, ice packs) Sedation if shivering occurs
Choice B rationale:
Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine is often required in septic shock to: Improve cardiac output: These agents increase myocardial contractility and heart rate, enhancing blood flow to vital organs.
Maintain blood pressure: They support vasoconstriction, counteracting the widespread vasodilation characteristic of septic shock.
Improve tissue perfusion: By optimizing cardiac output and blood pressure, they help ensure adequate oxygen and nutrient delivery to tissues.
Choice E rationale:
Blood cultures from all suspected sources before administration of antibiotics are essential for guiding appropriate antibiotic therapy.
Early identification of the causative organism: This information is crucial for selecting the most effective antibiotic regimen.
Prevention of antibiotic resistance: Judicious use of antibiotics based on culture results helps prevent the development of antibiotic-resistant bacteria.
Choice F rationale:
Vigorous intravenous fluid resuscitation with 0.9% sodium chloride is a cornerstone of septic shock management.
Replenishing intravascular volume: Septic shock often causes profound intravascular volume depletion due to capillary leak and vasodilation. Fluid resuscitation aims to restore circulating volume and maintain organ perfusion.
Improving hemodynamic stability: By increasing preload and cardiac output, fluids help stabilize blood pressure and support vital organ function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Metabolic alkalosis is characterized by a high pH (above 7.45), high bicarbonate (HCO3-) levels, and normal or low PaCO2. The patient's ABGs show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg), which are not consistent with metabolic alkalosis.
Choice C rationale:
Respiratory alkalosis is characterized by a high pH (above 7.45), low PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low PaCO2, but the pH is low (acidic) and the bicarbonate is low, which are not consistent with respiratory alkalosis.
Choice D rationale:
Respiratory acidosis is characterized by a low pH (below 7.35), high PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low pH, but the PaCO2 is also low, which is not consistent with respiratory acidosis.
Rationale for the correct answer, B:
Metabolic acidosis is characterized by a low pH (below 7.35), low bicarbonate levels, and normal or low PaCO2. The patient's ABGs are consistent with metabolic acidosis because they show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg).
Acute kidney injury is a common cause of metabolic acidosis. The kidneys play a vital role in regulating acid-base balance by excreting acids and reabsorbing bicarbonate. When the kidneys are damaged, they are unable to excrete acids effectively, leading to an accumulation of acids in the blood and a decrease in bicarbonate levels.
Additional Information:
It's important to note that the patient's low PaCO2 is likely a compensatory mechanism for the metabolic acidosis. In response to acidosis, the respiratory system tries to increase ventilation to blow off more carbon dioxide, which helps to raise the pH. However, this compensatory mechanism is often not enough to fully correct the acidosis.
Correct Answer is B
Explanation
Choice A rationale:
Removing the tube immediately upon patient gagging is not the most appropriate first step. Gagging is a common reflex during nasogastric tube insertion and can often be managed without removing the tube.
Premature removal could lead to unnecessary discomfort for the patient and potential delays in treatment.
The nurse should attempt to reposition the tube or have the patient sip water to facilitate passage before considering removal.
Choice B rationale:
Tucking the chin to the chest and swallowing are essential maneuvers that help guide the tube into the esophagus and reduce the risk of misplacement into the trachea.
These actions close off the airway and open the esophagus, creating a smoother path for the tube.
The nurse should instruct the patient to perform these actions during insertion to promote successful placement.
Choice C rationale:
While a supine position is often used for nasogastric tube insertion, it is not the most crucial factor for success.
Studies have shown that a high-Fowler's position (sitting upright with head elevated) may be equally effective and potentially more comfortable for patients.
The nurse should consider patient comfort and potential contraindications (such as respiratory distress) when choosing the most appropriate position.
Choice D rationale:
Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement. The correct measurement is from the nose tip to the earlobe to the xiphoid process (NEX).
This landmark-based method provides a more reliable estimation of the distance to the stomach.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.