The initial bundle of care in sepsis includes which of the following? (Select all that apply.)
Administer anti-hypertensives
Obtain blood cultures
Administer broad spectrum antibiotics
Obtain lactate levels
Administer IV fluid bolus
Correct Answer : B,C,D,E
The initial bundle of care in sepsis includes the following:
- Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
- Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
- Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
- Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
- Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Glipizide is an oral antidiabetic medication commonly prescribed to manage type 2 diabetes. It works by stimulating the release of insulin from the pancreas, which helps lower blood glucose levels. However, there is a risk of hypoglycemia (low blood sugar) with the use of Glipizide.
It is crucial for the client to be aware of the signs and symptoms of hypoglycemia so that they can take appropriate action if their blood sugar drops too low. These symptoms may include sweating, trembling, dizziness, confusion, weakness, and hunger. By recognizing these signs, the client can promptly address hypoglycemia by consuming a source of fast-acting glucose, such as fruit juice or glucose tablets, as instructed by their healthcare provider.
Correct Answer is D
Explanation
Fat embolism syndrome can occur when fat globules enter the bloodstream after a long bone fracture, such as a femur fracture. The fat globules can travel to the lungs and cause respiratory distress and decreased oxygen saturation. The symptoms observed in the client, including tachypnea (labored breathing), decreased oxygen saturation (88%), and the presence of petechiae (small red or purple spots) on the neck and anterior chest, are consistent with fat embolism syndrome.

Fat embolism syndrome is a serious condition that requires immediate medical attention. Notifying the healthcare provider allows for prompt evaluation, confirmation of the diagnosis, and initiation of appropriate treatment. This may involve further diagnostic tests such as a chest CT scan, as mentioned in one of the options, to rule out other potential causes or complications.
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