A patient with septic shock 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 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Acetaminophen (Tylenol) 650 mg rectally.

Start insulin drip to maintain blood glucose at 110 to 150 mg/dl.

Administer normal saline IV at 500 mL/hr.

Start norepinephrine to keep blood pressure above 90 mm Hg.

Answer and Explanation

The Correct Answer is C

C. The first intervention should be to administer normal saline IV at 500 mL/hr to address the immediate concern of hypotension and inadequate tissue perfusion.

A. While fever control is important, especially in septic shock, administering acetaminophen should not be the first intervention in a patient with severe hypotension and shock. Addressing the low blood pressure and perfusion is a higher priority.

B. Hyperglycemia is common in critically ill patients, including those with septic shock. However, in this scenario, the patient's severely low blood pressure and signs of shock take precedence over managing hyperglycemia. Insulin therapy can be initiated later once the patient's hemodynamic status is stabilized.

D. Norepinephrine is a vasopressor medication commonly used in septic shock to increase blood pressure and improve perfusion to vital organs. It helps counteract the vasodilation and hypotension characteristic of septic shock.

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Correct Answer is ["C","D","E","F"]

Explanation

A. Administering antibiotics helps target the suspected infection and prevent its spread. Broad-spectrum antibiotics are typically initiated until the specific pathogen is identified through cultures. This action should be completed as soon as possible within the first hour.

D. Lactate measurement is important in assessing tissue perfusion and the severity of sepsis. Elevated lactate levels indicate tissue hypoperfusion and can help identify patients at higher risk of mortality. Monitoring lactate levels guides resuscitation efforts and helps in assessing the response to treatment.

E. Fluid resuscitation is a cornerstone in the management of sepsis. Administering a large volume of intravenous fluids helps restore intravascular volume, improve tissue perfusion, and prevent further organ dysfunction. The recommended initial fluid bolus is 30 ml/kg of crystalloid solution, such as normal saline, administered rapidly within the first few hours of recognition of sepsis.

F. Blood cultures help identify the causative organism(s) responsible for the sepsis. This information is crucial for guiding antibiotic therapy, especially in cases of severe sepsis or septic shock. Blood cultures should be obtained before initiating antibiotic therapy to maximize their sensitivity and specificity.

B. Type and cross-match for packed red blood cells (PRBCs) are indicated in situations where blood transfusion may be required, such as severe anemia or active bleeding. While sepsis can lead to various complications, such as disseminated intravascular coagulation (DIC), the priority in the first hour is resuscitation and antibiotic administration.

G. Obtaining a urine specimen may be indicated to assess for urinary tract infection (UTI), which can be a potential source of sepsis. However, in the initial management of sepsis, obtaining blood cultures (option F) takes precedence as blood cultures provide more critical information for guiding antibiotic therapy.

H. Obtaining a wound culture may help identify the specific pathogens present in the wound and guide antibiotic therapy if the wound is suspected to be the source of sepsis. However, in the first hour of managing sepsis, the priority is to initiate broad-spectrum antibiotics and obtain blood cultures, as these interventions are more urgent in preventing further complications from sepsis.

A. Respiratory rate 22 breaths/min B. Heart rate 106 beats/min C. 02 saturation of 99% D. Crackles audible at lung bases

Correct Answer is D

Explanation

D Crackles audible at the lung bases indicate the presence of pulmonary edema or fluid accumulation in the alveoli, which can compromise gas exchange and exacerbate respiratory distress. In a patient with ARDS, crackles suggest worsening pulmonary status and may indicate inadequate ventilation or oxygenation despite mechanical ventilation. Therefore, crackles at the lung bases are the most important finding to report to the healthcare provider as they may indicate a need for adjustments to the ventilator settings or additional interventions to optimize respiratory function and prevent further deterioration.

A respiratory rate of 22 breaths/min may be within an acceptable range, particularly considering that the patient is receiving mechanical ventilation. However, any significant deviation from the baseline respiratory rate or signs of respiratory distress, such as increased work of breathing or accessory muscle use, should be closely monitored and reported promptly.

B A heart rate of 106 beats/min may be within an acceptable range, although it is slightly elevated. Tachycardia can occur due to various factors, including pain, anxiety, fever, or hypoxemia. While tachycardia warrants close monitoring, it may not be the most critical finding to report unless it is associated with hemodynamic instability or other concerning symptoms.

C An oxygen saturation of 99% indicates adequate oxygenation, which is reassuring, particularly in a patient with acute respiratory distress syndrome (ARDS). However, oxygen saturation alone may not reflect the adequacy of ventilation or the severity of the underlying lung injury. Therefore, while oxygen saturation should be monitored closely, it may not be the most critical finding to report unless it declines significantly or is accompanied by other concerning symptoms.

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A patient with septic shock 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 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 73-year-old client in the emergency department (ED) Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

Correct Answer is ["C","D","E","F"]

Explanation

Correct Answer is D

Explanation

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