A patient with sepsis has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 245 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Give 0.9% Sodium Chloride fluid bolus.

Give Pantoprazole (Protonix 40 mg IV push dally.

Give Acetaminophen (Tyler) 550 mg rectally.

Give rapid acting insulin per sliding scale.

Answer and Explanation

The Correct Answer is A

The patient's vital signs indicate signs of septic shock, including low blood pressure (70/46 mm Hg), tachycardia (136 beats/min), and tachypnea (32 breaths/min). The patient also has a high temperature of 104°F, indicating a fever. These findings suggest a systemic response to an infection that is leading to inadequate tissue perfusion.The initial treatment for septic shock includes fluid resuscitation to improve blood pressure and tissue perfusion. A fluid bolus of 0.9% Sodium Chloride (normal saline) is commonly used to restore intravascular volume in septic shock. It helps to increase blood pressure, improve organ perfusion, and stabilize the patient's condition.

The other interventions, such as administering Pantoprazole (Protonix) for gastrointestinal protection, giving Acetaminophen (Tylenol) for fever control, or administering rapid-acting insulin per sliding scale for hyperglycemia, are important aspects of care but should be implemented after the initial fluid resuscitation. The priority at this moment is to address the patient's hypotension and inadequate tissue perfusion through the administration of fluid bolus.

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Correct Answer is C

Explanation

Bowel sounds are the result of muscular contractions in the intestines, indicating the movement of food, fluids, and gas through the gastrointestinal tract. After surgery, the normal function of the intestines, including peristalsis, may be temporarily impaired. As the intestines recover and regain their normal motility, bowel sounds will become audible.

The return of bowel sounds is an encouraging sign that the gastrointestinal system is starting to function again. It indicates that peristaltic activity has resumed and that the intestines are moving and processing the contents within. This is an essential step in the postoperative recovery process, as it indicates the return of normal gastrointestinal function and can lead to the resumption of oral intake and passage of stool.

While the other options may also be associated with the return of GI function, such as feeling hungry or passing flatus or stool, the presence of bowel sounds is a more reliable and direct assessment finding that indicates the resumption of peristaltic activity.

A. "The red blood cell count should begin to improve with these injections B. "My Cr and BUN will slowly improve over the next 7-10 days. C. I will not have to take Furosemide any longer. D. Urine output should improve with these injections.

Correct Answer is A

Explanation

Recombinant human erythropoietin is a medication commonly used in the treatment of anemia associated with chronic renal failure. It stimulates the production of red blood cells in the bone marrow, helping to improve anemia.

The other statements mentioned do not accurately reflect the expected outcomes or effects of recombinant human erythropoietin:

Chronic renal failure leads to impaired kidney function, and while recombinant human erythropoietin can help address anemia, it does not directly improve creatinine (Cr) and blood urea nitrogen (BUN) levels, which are markers of kidney function.

Furosemide is a diuretic commonly used in the management of fluid retention in renal failure. Recombinant human erythropoietin does not replace or eliminate the need for diuretic therapy.

Chronic renal failure typically involves decreased kidney function and impaired urine production. Recombinant human erythropoietin does not directly affect urine output.

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A patient with sepsis has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 245 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding is the best Indicator to the nurse that a client's peristaltic activity (Gl motility) has resumed after surgery?

Correct Answer is C

Explanation

The nurse is teaching a client with chronic renal failure (CRF) about the use of recombinant human erythropoietin (Epogen) Subcutaneous injections. Which statement indicates the client understands the teaching?

Correct Answer is A

Explanation

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