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 B

Explanation

Choice A reason: Encouraging the patient to continue an exercise routine such as weightlifting is not appropriate for a patient with esophageal varices. Weightlifting and other strenuous activities can increase intra-abdominal pressure, which may lead to the rupture of the varices and cause severe bleeding.

Choice B reason: Advising the patient to avoid straining at stools is the correct intervention. Straining during bowel movements can increase intra-abdominal pressure and the risk of rupturing the esophageal varices. The nurse should encourage the patient to maintain soft stools through a high-fiber diet, adequate hydration, and possibly stool softeners to prevent straining.

Choice C reason: Providing hot liquids as desired is not recommended for patients with esophageal varices. Hot liquids can cause vasodilation and potentially increase the risk of bleeding from the varices. Patients should be advised to consume beverages at moderate temperatures.

Choice D reason: Advising the patient to limit themselves to one alcoholic drink per day is not appropriate. Alcohol consumption can worsen liver disease, increase portal hypertension, and exacerbate esophageal varices. Patients with esophageal varices should be advised to avoid alcohol completely to reduce the risk of complications.

A. Percutaneous Coronary Intervention (PCI). B. Echocardiography. C. Exercise testing. D. Electrocardiography.

Correct Answer is B

Explanation

Choice A reason: Percutaneous Coronary Intervention (PCI) is a procedure used to open narrowed coronary arteries, usually with a balloon or stent. It is not a diagnostic test for assessing heart valves but rather a treatment for coronary artery disease.

Choice B reason: Echocardiography is a non-invasive imaging test that uses ultrasound waves to create detailed images of the heart's structures, including the heart valves. It allows for the assessment of valve function, structure, and blood flow, making it an essential tool for diagnosing valvular heart disease.

Choice C reason: Exercise testing, also known as a stress test, evaluates the heart's response to physical activity. While it can provide information on how well the heart handles increased workload and detect issues like ischemia, it is not specifically used for assessing heart valves.

Choice D reason: Electrocardiography (ECG or EKG) records the electrical activity of the heart and is used to detect arrhythmias, heart attacks, and other cardiac conditions. However, it does not provide detailed information about the heart valves' structure or function.

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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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Naxlex Comprehensive Predictor Exams

Considering the patient's esophageal varices, which of the following nursing interventions would be appropriate in your care of the patient?

Correct Answer is B

Explanation

The healthcare provider recommends to a patient that diagnostic testing be performed to assess for valvular heart disease. The nurse teaches the patient about which test that is commonly used to assess the valves?

Correct Answer is B

Explanation

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