The nurse is reviewing orders received for a client diagnosed with sepsis. Which order should the nurse question?
Administer oxygen via mask.
Obtain serum lactate level.
Infuse 0.9% NS at 50 mL/hr.
Obtain blood and urine cultures.
The Correct Answer is C
Choice A reason: Administering oxygen via mask is appropriate for a client with sepsis who may have compromised oxygenation.
Choice B reason: Obtaining a serum lactate level is important in sepsis as it can indicate the severity of the condition and guide treatment.
Choice C reason: An infusion rate of 0.9% Normal Saline at 50 mL/hr may be questioned because clients with sepsis may require more aggressive fluid resuscitation.
Choice D reason: Obtaining blood and urine cultures is essential before starting antibiotics to identify the causative organism in sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. Urine output 60 mL.
Choice A reason: A pulse oximetry reading of 96% is within normal limits and does not indicate an ineffective response to the medications.
Choice B reason: A heart rate of 77, regular, is also within normal limits and does not suggest an ineffective response.
Choice C reason: Trace bilateral ankle edema may persist even after effective treatment due to residual effects of heart failure.
Choice D reason: A urine output of 60 mL over 2 hours post-diuretic administration suggests an inadequate response, as furosemide is expected to produce a significant diuresis to reduce fluid overload in acute heart failure.
Correct Answer is C
Explanation
Choice A reason: While assessing temperature is important for monitoring infection, it is not the immediate priority in the treatment of UTI and sepsis.
Choice B reason: Monitoring urine output is crucial for a UTI but does not address the systemic infection that sepsis represents.
Choice C reason: Administering antibiotics is the most critical intervention for a client with sepsis due to a UTI, as it directly addresses the underlying infection and can be life-saving.
Choice D reason: Evaluating the current CBC is important for understanding the client's baseline and response to infection but is secondary to the administration of antibiotics.
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