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A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?
- A. All my friends and neighbors are planning a party for me.
- B. I hope I can get my water turned back on when I get home.
- C. My neighbor has several cats with litter boxes in the home.
- D. My grandkids are so excited to have me coming home.
Correct Answer: B
Rationale: Lack of access to clean water (implied by the hope to get water turned back on) increases the risk of infection due to poor hygiene, especially with an unhealed wound. This poses a higher risk for sepsis compared to social gatherings, exposure to litter boxes, or family excitement.
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A nurse caring for a client notes the following assessments: white blood cell count 3800/mm³, temperature 96.8°F, and weak pedal pulses. What action by the nurse takes priority?
- A. Document the findings in the client's chart.
- B. Give the client warmed blankets for comfort.
- C. Notify the health care provider immediately.
- D. Prepare to administer insulin per sliding scale.
Correct Answer: C
Rationale: This client has several indicators of sepsis with systemic inflammatory response, such as low white blood cell count, hypothermia, and poor perfusion (weak pulses). The nurse should notify the health care provider immediately to initiate prompt treatment. Documentation and comfort measures are important but not the priority. Insulin may not be needed in this scenario.
A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
- A. Alert and oriented, answering questions.
- B. Client denial of chest pain or chest pressure.
- C. IV site without redness or swelling.
- D. Urine output of 30 mL/hr for 2 hours.
Correct Answer: A
Rationale: Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine, which improves perfusion to vital organs, including the brain. Absence of chest pain, normal IV site, and minimal urine output do not specifically indicate the therapeutic effect of norepinephrine.
A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last checked 3 hours ago. What action by the nurse is best?
- A. Ask if the client needs pain medication.
- B. Assess the client's tissue perfusion further.
- C. Document the findings in the client's chart.
- D. Increase the rate of the client's IV infusion.
Correct Answer: B
Rationale: Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, and blood pressure. Although these readings are not out of the normal range, the nurse should perform a thorough assessment of the client, focusing on indicators of perfusion to detect early shock. Pain medication and documentation are important but not the priority. Increasing IV infusion rate requires a medical order and is not the first action.
A client with severe sepsis has a serum lactate level of 6.2 mmol/L. What is the priority nursing action?
- A. Administer oxygen via nasal cannula.
- B. Notify the health care provider immediately.
- C. Increase the IV fluid infusion rate.
- D. Administer insulin per sliding scale.
Correct Answer: B
Rationale: A serum lactate level of 6.2 mmol/L indicates severe sepsis with tissue hypoperfusion, requiring immediate notification of the health care provider to initiate aggressive treatment, such as fluids, antibiotics, or vasopressors. Oxygen, increased fluids, or insulin may be needed but are not the priority without provider orders.
The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.)
- A. Administer antibiotics.
- B. Draw serum lactate levels.
- C. Infuse vasopressors.
- D. Obtain blood cultures.
- E. Measure central venous pressure.
Correct Answer: A,B,D
Rationale: Within the first 3 hours of suspecting severe sepsis, the nurse should facilitate obtaining blood cultures, drawing serum lactate levels, and administering antibiotics (after cultures). Infusing vasopressors and measuring central venous pressure are typically performed within 6 hours.