An immunocompromised older adult has developed a urinary tract infection, and the healthcare team recognizes the need to prevent an exacerbation of the client's infection that could result in sepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock?
Insert a new indwelling urinary catheter
Collect blood cultures
Initiate intravenous (IV) antibiotics
Obtain placement of an intravenous access for fluid administration
The Correct Answer is C
A. Inserting a new indwelling urinary catheter could introduce new pathogens and increase the risk of infection rather than reduce it. Indwelling catheters are a known risk factor for urinary tract infections and should be avoided if possible.
B. Collecting blood cultures is an important diagnostic step, especially if sepsis is suspected. However, this action alone does not directly reduce the risk of septic shock. It is a part of the process but not the most immediate intervention.
C. Initiating intravenous (IV) antibiotics is the most critical intervention to reduce the risk of septic shock. Prompt administration of antibiotics can help control the infection before it progresses to sepsis, making this the priority action.
D. Obtaining placement of an intravenous access for fluid administration is necessary for managing sepsis or septic shock, but the first step should be administering antibiotics to treat the infection causing the sepsis. Fluid administration supports blood pressure and circulation but does not directly address the underlying infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Vasopressin does not typically increase the client's heart rate; its primary effect is on the kidneys and urine output.
B. Vasopressin generally increases blood pressure by promoting vasoconstriction, not decreases it.
C. Vasopressin will increase, not decrease, urine specific gravity by reducing urine output and concentrating the urine.
D. Vasopressin acts to decrease urine output by increasing water reabsorption in the kidneys, which helps manage diabetes insipidus.
Correct Answer is D
Explanation
A. Placing the client on a ventilator to remove CO2 is not directly related to preventing the development of MODS. While ventilation might be necessary for respiratory support, it does not address the systemic infection and inflammation that contribute to MODS.
B. Advising the client to use their call light to reduce the risk of falls is important for general safety but does not address the critical factors involved in preventing MODS in the context of SIRS.
C. Providing a high protein diet can support overall nutrition and healing but is not the primary intervention for preventing MODS. Managing the infection and maintaining hemodynamic stability are more critical.
D. Administering antibiotics to treat the bacterial infection and maintaining a mean arterial pressure (MAP) of at least 65 mm Hg are essential interventions. Effective antibiotic therapy addresses the infection, and maintaining MAP ensures adequate organ perfusion, both of which help prevent the progression to MODS.
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