The nurse is caring for a patient in septic shock with a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (5p02) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first?

Blood Cultures

Foley insertion

Serum electrolytes

Chest x-ray

Answer and Explanation

The Correct Answer is A

Rationale:
A. Blood cultures are correct because obtaining cultures before starting antibiotics is essential in septic shock. Identifying the causative organism guides targeted antimicrobial therapy. Administering antibiotics before cultures may reduce the yield, making it harder to identify the pathogen. This is a time-sensitive priority in sepsis management.

B. Foley insertion is incorrect as it is used for strict urine output monitoring, which is important in septic shock but not immediately urgent before starting antibiotics. It can be done after cultures are obtained and antibiotic therapy is initiated.

C. Serum electrolytes are important to monitor for organ dysfunction or imbalances in septic shock, but obtaining them is not as urgent as obtaining cultures prior to antibiotics. Delaying antibiotics to wait for labs could worsen outcomes.

D. Chest x-ray may be indicated if a pulmonary source of infection is suspected, but it is not the highest priority. Blood cultures should be drawn first because early antibiotic administration after culture collection is critical to reduce morbidity and mortality in septic shock.

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Correct Answer is D

Explanation

Rationale:
A. Progressive is incorrect because this stage of shock occurs after the compensatory stage when the body’s mechanisms begin to fail, leading to tissue hypoperfusion, worsening acidosis, and organ dysfunction. However, interventions at this stage can still potentially reverse damage if promptly addressed.

B. Compensatory is incorrect because, in this early stage, the body activates mechanisms such as increased heart rate, vasoconstriction, and respiratory changes to maintain perfusion. Tissue perfusion is still adequate, and damage is usually reversible.

C. Initial is incorrect because this is the very beginning of shock, often asymptomatic, where cellular changes begin but clinical signs may be minimal. Early interventions are highly effective at this stage.

D. Refractory is correct because this is the final stage of shock, sometimes called irreversible shock. In this stage, prolonged hypoperfusion and cellular injury lead to widespread organ failure. Even with aggressive treatment, the damage is often irreversible, and death is likely.

A. CAUTI B. Sepsis C. CLABSI D. VAP

Correct Answer is B

Explanation

Rationale:
A. CAUTI (Catheter-Associated Urinary Tract Infection) is incorrect because, although burn patients often require indwelling urinary catheters for strict intake and output monitoring, CAUTIs are typically localized infections. They are rarely the direct cause of death and do not account for the high mortality seen in patients with severe burns.

B. Sepsis is correct because it is the leading cause of death in patients with severe burns. Burn injuries destroy the skin, which is the body’s primary barrier against infection. This allows bacteria to easily enter the bloodstream. Additionally, burn patients experience immune system suppression and a massive inflammatory response, increasing the risk of systemic infection, septic shock, multiple organ dysfunction, and death.

C. CLABSI (Central Line–Associated Bloodstream Infection) is incorrect because, while central lines are commonly used in burn patients and can lead to bloodstream infections, CLABSIs represent only one possible source of infection. They are not the most common overall cause of death compared with widespread sepsis from burn wounds.

D. VAP (Ventilator-Associated Pneumonia) is incorrect because some burn patients require mechanical ventilation, especially those with inhalation injuries. Although VAP is a serious complication, it is less common than sepsis as the primary cause of mortality in severe burn patients.

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Naxlex Comprehensive Predictor Exams

In this stage of shock, if the cause is not corrected, damages become more severe and may be irreversible. What stage is this?

Correct Answer is D

Explanation

What is the primary cause of death in patients with severe burns?

Correct Answer is B

Explanation

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