The nurse has just completed an infusion of a 1000 ml bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action?
Sodium 140 mEq/L
Lactate 6 mmol/L
Potassium 3.8 mEq/L
Creatinine 1.0 mg/dl
The Correct Answer is B
Rationale:
A. This value is within the normal range (135–145 mEq/L). Although sepsis and aggressive fluid resuscitation can alter sodium levels, a value of 140 mEq/L does not require immediate intervention.
B. Lactate is a marker of tissue hypoperfusion and anaerobic metabolism. In severe sepsis, a lactate level >4 mmol/L indicates that organs and tissues are not receiving adequate oxygen despite fluid resuscitation. This suggests ongoing septic shock. Immediate nursing actions include notifying the provider, ensuring adequate IV access for further fluid resuscitation, monitoring vital signs and urine output, and preparing for additional sepsis interventions such as vasopressors or antibiotics if indicated. Persistently high lactate is associated with increased mortality and signals the need for rapid escalation of care.
C. This is within normal limits (3.5–5.0 mEq/L). While potassium must be monitored in sepsis due to risks of hypo- or hyperkalemia from fluid shifts, medications, or renal impairment, a value of 3.8 mEq/L does not require urgent intervention.
D. This value is within normal limits (0.6–1.3 mg/dL). Creatinine reflects kidney function, which can be affected in sepsis; however, at this level, there is no acute kidney injury, and it does not necessitate immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Agitation is incorrect because it is a hallmark of hyperactive delirium. Patients with hyperactive delirium may be visibly restless, aggressive, or emotionally labile, often exhibiting behaviors such as shouting, pacing, or striking out. Agitation is not characteristic of hypoactive delirium.
B. Restlessness is incorrect for hypoactive delirium; it is typically seen in hyperactive delirium. Restlessness includes constant movement, fidgeting, or an inability to stay calm, which contrasts with the lethargy seen in hypoactive states.
C. Hitting is incorrect because combative or aggressive behaviors occur in hyperactive delirium, not hypoactive delirium. Patients in the hypoactive state are more passive and withdrawn rather than outwardly aggressive.
D. Withdrawal is correct because hypoactive delirium is characterized by reduced psychomotor activity, lethargy, decreased responsiveness to the environment, and social withdrawal. Patients may appear drowsy, quiet, and unengaged, often seeming “sleepy” or “apathetic.” They may show minimal interaction with staff or family, have slowed speech, and be less likely to communicate discomfort or needs.
Correct Answer is B
Explanation
Rationale:
A. Drawing blood from the left arm is incorrect because venipuncture or IV insertion should be avoided in the arm with a newly created arteriovenous (AV) fistula. Puncturing the fistula can damage it, compromise future dialysis access, and increase the risk of infection or thrombosis.
B. Auscultating for a bruit and palpating for a thrill is correct because this is the standard assessment to ensure AV fistula patency. A thrill is a palpable vibration over the fistula, and a bruit is a whooshing sound heard with a stethoscope. Monitoring these ensures the fistula is functioning properly for future hemodialysis.
C. Taking blood pressure from the left arm every 4 hours is incorrect because blood pressure should never be taken on the arm with a fistula, as it can cause trauma, clotting, or compromise blood flow to the fistula. The right arm or another site should be used.
D. Starting a new intravenous line in the left lower arm is incorrect because IV access should ideally be placed in the opposite arm or another site to preserve the fistula for dialysis access.
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