The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2°F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next?

Give the PRN acetaminophen (Tylenol).

Notify the health care provider of these findings.

Obtain oxygen saturation using pulse oximetry.

Give the scheduled IV antibiotic.

Answer and Explanation

The Correct Answer is B

Choice A reason: Acetaminophen reduces fever, but 101.2°F isn’t critical in sepsis, where hypotension (90/56 mmHg) signals shock. Addressing fever alone ignores systemic instability, delaying urgent intervention for a deteriorating patient needing comprehensive management.

Choice B reason: Hypotension (90/56 mmHg) and tachypnea (34 breaths/min) indicate septic shock, requiring immediate escalation. Notifying the provider ensures rapid fluid resuscitation and vasopressors, critical in gram-negative sepsis to reverse hypoperfusion and prevent organ failure.

Choice C reason: Pulse oximetry assesses oxygenation, useful in sepsis with tachypnea. However, hypotension is more immediately life-threatening, prioritizing provider notification for systemic treatment over a single parameter check that delays broader stabilization efforts.

Choice D reason: IV antibiotics target sepsis’s cause, but a scheduled dose doesn’t address acute hypotension urgency. Provider notification supersedes routine administration, as shock requires fluids and pressors now, not just infection control, to save the patient.

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Correct Answer is ["A","D","E"]

Explanation

Choice A reason: Cilostazol inhibits phosphodiesterase III, increasing cyclic AMP, which dilates arteries and reduces platelet aggregation. This improves blood flow and reduces intermittent claudication in PAD, directly targeting vascular symptoms by enhancing circulation and preventing thrombosis, making it a primary treatment option.

Choice B reason: Ramipril, an ACE inhibitor, lowers blood pressure and protects vascular endothelium, benefiting PAD indirectly. It reduces cardiovascular strain but doesn’t directly improve limb perfusion or claudication, so it’s not a primary PAD medication despite its role in managing comorbidities like hypertension.

Choice C reason: Metoprolol, a beta-blocker, slows heart rate and reduces myocardial oxygen demand, useful in heart disease. In PAD, it may worsen claudication by reducing peripheral blood flow via vasoconstriction, making it less commonly prescribed specifically for PAD management.

Choice D reason: Aspirin inhibits cyclooxygenase, reducing thromboxane A2 and platelet aggregation. This antiplatelet action prevents clot formation in narrowed PAD arteries, improving outcomes by reducing thrombotic events, making it a standard, evidence-based therapy for symptom relief and risk reduction.

Choice E reason: Clopidogrel blocks ADP receptors on platelets, preventing aggregation and thrombus formation. In PAD, it reduces ischemic events and improves patency, often used alone or with aspirin, making it a key medication for managing vascular complications and symptoms.

A. Blood glucose level of 122 mg/dL (Normal 70-110 mg/dL) B. Serum hemoglobin of 14.7 g/dL (Normal 12-18 g/dL) C. Serum potassium of 4.5 mEq/L (Normal 3.5-5.0 mEq/L) D. Serum creatinine of 2.8 mg/dL (normal 0.5-1.2 mg/dL)

Correct Answer is D

Explanation

Choice A reason: Glucose of 122 mg/dL is mildly elevated, suggesting prediabetes, but not urgent in hypertension. It’s a chronic risk factor, less critical than renal function for immediate provider attention.

Choice B reason: Hemoglobin of 14.7 g/dL is normal (12-18 g/dL), requiring no action in hypertension. It reflects oxygen capacity, not directly tied to blood pressure or acute complications needing reporting.

Choice C reason: Potassium of 4.5 mEq/L is normal (3.5-5.0 mEq/L), not concerning in hypertension. It’s relevant with medications, but this value alone doesn’t warrant immediate communication to the provider.

Choice D reason: Creatinine of 2.8 mg/dL (normal 0.5-1.2 mg/dL) indicates renal impairment, critical in hypertension. It suggests kidney damage from pressure, needing urgent reporting to adjust treatment and prevent progression.

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The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2°F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is D

Explanation

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