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","C","D","E"]

Explanation

Choice A reason: Antivirals like oseltamivir reduce influenza severity and duration by inhibiting viral replication. Administering them as prescribed is a key nursing action, supporting recovery and aligning with medical orders in interprofessional influenza care.

Choice B reason: Strict bedrest isn’t required for influenza; moderate activity aids recovery by preventing complications like pneumonia. Evidence favors rest as needed, not enforced immobility, making this less critical in a collaborative plan.

Choice C reason: Educating about annual vaccinations prevents future influenza via antibody production. It’s a proactive nursing role, enhancing patient autonomy and public health, integral to long-term interprofessional management strategies.

Choice D reason: Hydration and rest support immune function and symptom relief in influenza. Encouraging this replaces losses from fever, a fundamental nursing action enhancing recovery in collaboration with the healthcare team.

Choice E reason: Isolation via droplet precautions prevents influenza spread, a core nursing responsibility. It protects others, aligning with infection control protocols, making it essential in interprofessional care for a contagious patient.

A. Metabolic alkalosis with hypoxemia B. Respiratory alkalosis with hypoxemia C. Metabolic acidosis with hypoxemia D. Respiratory acidosis with hypoxemia

Correct Answer is B

Explanation

Choice A reason: Metabolic alkalosis shows pH >7.45 with HCO3- >26 mEq/L from base excess. Here, pH is 7.48, but HCO3- is normal at 24 mEq/L, ruling out metabolic cause. PaO2 of 55 mmHg indicates hypoxemia, but the primary issue isn’t metabolic.

Choice B reason: Respiratory alkalosis occurs with pH >7.45 and PaCO2 <35 mmHg from hyperventilation. Here, pH is 7.48, PaCO2 is 28 mmHg, and HCO3- is normal, confirming respiratory etiology. PaO2 of 55 mmHg shows hypoxemia, matching this acute ventilatory pattern.

Choice C reason: Metabolic acidosis has pH <7.35 and HCO3- <22 mEq/L from acid gain. Here, pH is 7.48 and HCO3- is 24 mEq/L, contradicting acidosis. PaO2 of 55 mmHg indicates hypoxemia, but the acid-base status is alkalotic, not acidic.

Choice D reason: Respiratory acidosis features pH <7.35 and PaCO2 >45 mmHg from CO2 retention. Here, pH is 7.48 and PaCO2 is 28 mmHg, showing CO2 loss, not retention. Hypoxemia (PaO2 55 mmHg) is present, but the pattern is alkalotic.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student is learning about the interprofessional management of a patient diagnosed with influenza. Which of the following actions should the nursing student include in their care plan when collaborating with the healthcare team? (Select all that apply)

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

Explanation

Interpret the ABG results: pH: 7.48, PaCO2: 28 mmHg, PaO2: 55 mmHg, HCO3-: 24 mEq/L, SaO2: 87%

Correct Answer is B

Explanation

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