The nurse is caring for a newly admitted patient with sepsis and has received orders from the physician. What order should the nurse implement first?

Finger-stick glucose.

Blood cultures x2.

Tylenol 650 mg PO.

Vancomycin 760 mg IV.

Answer and Explanation

The Correct Answer is B

Choice A reason: Finger-stick glucose is important for monitoring blood sugar levels, especially in septic patients who may develop hyperglycemia. However, it is not the highest priority compared to obtaining blood cultures and administering antibiotics.

Choice B reason: Obtaining blood cultures x2 is the first priority in managing a patient with sepsis. Identifying the causative organism and determining antibiotic susceptibility is crucial for guiding effective treatment. Blood cultures should be obtained before administering antibiotics to ensure accurate results.

Choice C reason: Tylenol (acetaminophen) 650 mg PO may be given to reduce fever and provide comfort, but it is not the highest priority in the initial management of sepsis. Immediate diagnostic and therapeutic interventions are more critical.

Choice D reason: Vancomycin 760 mg IV is an important antibiotic for treating sepsis, especially if a resistant organism is suspected. However, it should be administered after blood cultures are obtained to avoid contaminating the cultures and ensuring accurate identification of the causative organism.

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Correct Answer is D

Explanation

Choice A reason: The electrician who suffered external burn injuries a month ago is stable enough to be concerned with discharge plans. This indicates that his burns have been managed and he is in a phase of recovery where he is preparing for discharge. Although his request is important, it is not an immediate priority compared to more acute conditions.

Choice B reason: The older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body is in a critical condition and needs continuous monitoring, especially with high fluid administration. However, their condition is currently being managed with IV fluids. While this client requires close observation, there is no immediate indication of a life-threatening change that demands immediate intervention compared to the firefighter's situation.

Choice C reason: The adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain is also in need of pain management and ongoing care. However, pain, while significant and requiring treatment, does not take precedence over the potential airway compromise and respiratory distress posed by smoke inhalation and facial burns in the firefighter.

Choice D reason: The firefighter with smoke inhalation and facial burns who has just arrived on the unit must be assessed first due to the immediate risk of airway compromise and respiratory distress. Smoke inhalation can lead to rapid swelling of the airways, making it a critical emergency. Facial burns also increase the risk of airway obstruction. Prompt assessment and intervention are essential to ensure the firefighter's airway remains patent and to provide necessary respiratory support.

A. Explain ways to decrease paroxysmal nocturnal dyspnea. B. Discuss the effects of medications, ways to assess fluid balance, and positions for enhancing respirations. C. Teach stress management techniques. D. Provide a list of support systems in the community.

Correct Answer is B

Explanation

Choice A reason: Explaining ways to decrease paroxysmal nocturnal dyspnea is helpful for managing this specific symptom of heart failure, which involves difficulty breathing at night due to fluid accumulation in the lungs. While this can improve comfort, it doesn't provide a comprehensive approach to managing heart failure symptoms at home.

Choice B reason: Discussing the effects of medications, ways to assess fluid balance, and positions for enhancing respirations offers a comprehensive approach to managing heart failure symptoms at home. Understanding medication effects helps clients adhere to their treatment plan and manage side effects. Assessing fluid balance is crucial for detecting fluid overload early, a common issue in heart failure. Learning positions that enhance respirations can improve breathing and overall comfort.

Choice C reason: Teaching stress management techniques is beneficial for overall well-being and can indirectly improve heart health by reducing stress, which can exacerbate heart failure symptoms. However, it is not as directly related to managing the physical symptoms of heart failure as other interventions.

Choice D reason: Providing a list of support systems in the community is valuable for emotional and practical support, which can improve quality of life for clients with heart failure. However, it does not directly address the physical symptoms or management of heart failure at home.

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The nurse is caring for a newly admitted patient with sepsis and has received orders from the physician. What order should the nurse implement first?

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The nurse is caring for a newly admitted patient with sepsis and has received orders from the physician. What order should the nurse implement first?