Your patient, post-operative from a gastrointestinal surgery, presents with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT.

Which of the following findings indicate that the patient is progressing to septic shock? Select all that apply:

Patient requires Metoprolol (Lopresor) STAT

Patient requires Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement

Serum lactate less than 2 mmol/L

Blood pressure of 70/34 after the fluid bolus

Answer and Explanation

Correct Answer : B,D

Choice A rationale
The need for Metoprolol (Lopresor) STAT does not necessarily indicate progression to septic shock. Metoprolol is a beta-blocker used to treat high blood pressure, heart failure, and angina. While it may be used in the management of sepsis to control heart rate, its use does not specifically indicate progression to septic shock.
Choice B rationale
The need for Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement is a strong indicator of septic shock. Norepinephrine is a vasopressor, a type of medication used to increase blood pressure. In septic shock, vasopressors are often required to maintain adequate blood pressure and organ perfusion despite aggressive fluid resuscitation.
Choice C rationale
A serum lactate level less than 2 mmol/L is generally not indicative of septic shock. Elevated lactate levels can indicate tissue hypoperfusion, a condition that may occur in septic shock. However, a level less than 2 mmol/L is typically considered within the normal range.
Choice D rationale
A blood pressure of 70/34 after the fluid bolus could indicate progression to septic shock. In septic shock, despite aggressive fluid resuscitation, blood pressure often remains dangerously low, which can lead to inadequate blood flow to the organs.

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Correct Answer is B

Explanation

Choice A rationale
Evaluating the need for smoking cessation is a standard part of nursing care, especially for patients with circulatory issues. Smoking can exacerbate circulatory problems and delay wound healing.
Choice B rationale
Applying TED hose to both legs might not be appropriate for this patient. TED hose are compression stockings designed to prevent deep vein thrombosis and promote circulation. However, in a patient with weak pedal pulses and a full-thickness wound on the leg, the compression from the stockings could potentially worsen circulation to the area and impede wound healing.
Choice C rationale
Consulting with physical therapy could be beneficial for this patient. Physical therapists can provide exercises and interventions to improve circulation and mobility, which could help with the patient’s circulatory issues and wound healing.
Choice D rationale
Obtaining an Ankle-Brachial Index (ABI) using a hand-held Doppler could be useful in this situation. The ABI is a simple, non-invasive test that can help diagnose peripheral artery disease (PAD), a condition that could be causing the patient’s weak pedal pulses and wound healing issues.

A. Reduce anxiety and relieve pain. B. Improve myocardial oxygenation and reduce cardiac workload. C. Eliminate family stressors and provide a calm environment. D. Start the client on a low-sodium diet and decrease fluid intake.

Correct Answer is B

Explanation

Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a patient who has weak pedal pulses, no hair on both legs, and a full-thickness wound on the right lateral malleolus with defined margins, which includes a small amount of serous exudate. Which intervention should not be performed?

Correct Answer is B

Explanation

A client is admitted to the telemetry unit with an episode of substernal chest pain. His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level. What would be an appropriate initial nursing goal?

Correct Answer is B

Explanation

A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds. Which of the following findings should the nurse be most concerned about?

Which medication, when noted in a patient’s history, will diminish the effects of Warfarin (Coumadin)?

What is the most appropriate advice for a patient suffering from arterial insufficiency?

The nurse is administering nitroglycerin intravenously to alleviate chest pain. What is the therapeutic action of this medication?

Upon receiving a change-of-shift report about four patients in a heart failure unit, which patient should the nurse prioritize for assessment?

A 75-year-old male experiences severe chest pain and calls 911. Given that lab findings indicate elevated levels of cardiac troponins I and T, what condition does the nurse suspect?

A patient with dilated cardiomyopathy has recently developed atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

A nurse is caring for a patient who has undergone an angiogram. What should the nurse prioritize in assessing and documenting for this patient?