Nokea
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.
You may also like to solve these questions
A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)?
- A. It causes vasoconstriction and increased MAP.
- B. Lower blood volume lowers MAP.
- C. There is no direct correlation to MAP.
- D. It raises cardiac output and MAP.
Correct Answer: B
Rationale: Lower blood volume will decrease MAP because reduced blood volume leads to decreased cardiac output and subsequently lower pressure in the arterial system. The other answers are not accurate as they do not correctly describe the physiological response to blood loss.
A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene?
- A. Assessing the IV site before giving the drug.
- B. Obtaining a pump compatible with the IV site.
- C. Removing the IV bag from the brown plastic cover.
- D. Taking and recording a baseline set of vital signs.
Correct Answer: C
Rationale: Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct and appropriate.
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 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 several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider?
- A. Creatinine 0.6 mg/dL.
- B. Creatinine 6 mg/dL.
- C. Hemoglobin 12 g/dL.
- D. Potassium 4.0 mEq/L.
Correct Answer: B
Rationale: A creatinine level of 6 mg/dL is significantly elevated, indicating potential renal dysfunction, which is a critical concern in clients at risk for shock. The nurse should notify the health care provider immediately. The other values are within or near normal ranges.