Sepsis & Shock
The first intervention when caring for a client at risk for sepsis.
What is obtain a culture before beginning antibiotics?
The primary purpose of placing a client with ARDS in the prone position.
What is to improve ventilation and perfusion?
This lab value would indicate the client is at risk of or in shock.
What is lactate (ex. 5.4 mg/dL)?
The nurse would need to report what finding to the provider on a client receiving alteplase (Activase)?
What is hypertension (ex. BP 206/108 mmHg)?
The nurse is prioritizing which client to see first.
A. BP change from 128/74 to 110/88 mmHg
B. Unchanged O2 sat at 94%
C. HR change of 100 to 88 beats/min
D. UOP of 40 mL/hr for last 2 hours.
What is A?
The client who is most at risk for Systemic Inflammatory Response Syndrome (SIRS).
Who is the client admitted for sepsis and shock?
This is the first intervention for a client with suspected pulmonary embolism.
What is apply oxygen (usually via NC)?
The nurse would monitor this lab value to determine the effectiveness of therapy for a client on heparin.
What is an aPTT?
The client with septic shock needs this intervention immediately.
What is administering broad-spectrum antibiotics?
These assessment findings indicate oxygenation impairment requiring immediate intervention.
What are chest retractions, nasal flaring, use of accessory muscles?
This treatment takes priority within the first hour of septic shock treatment.
What is obtain a serum lactate level?
The following ABG indicate this type of _____
pH: 7.31
PaCO2: 50 mmHg
HCO3: 26 mEq/L
What is respiratory acidosis?
Continuous bubbling in the water seal chamber of a chest drainage system would alert the nurse of ___ in the system?
What is an air leak?
The nurse should take this action when the nursing student removes the sodium nitroprusside from its brown plastic cover.
What is intervene?
(The bag has to remain on the bag to prevent light exposure)
The client with pneumonia and hypotension requires this priority intervention.
What is administer intravenous fluids for fluid resuscitation?
The client with acute pancreatitis should be monitored for this type of shock.
What is hypovolemic shock?
Clients at the highest risk for PE.
What are post-surgical clients?
(Ex. Older client post hip replacement)
This finding would require immediate intervention in a recently extubated client.
What is inspiratory stridor?
This medication is a priority for a client with heart failure entering cardiogenic shock.
What is dobutamine?
Clients who are high risk for ARDS.
What are
-sepsis/septic shock
-MVC with major trauma
-near-drowning episode
This intervention is most important in managing multiple organ dysfunction syndrome (MODS).
What is treatment of the underlying cause/problem?
**Also most important to support the failing organ systems**
The symptoms would alert the nurse to possible atelectasis in a client on mechanical ventilation.
What are diminished lung sounds and decreased oxygen saturation?
These foods should be avoided/limited in a client taking warfarin (Coumadin).
What are brussel sprouts, broccoli, cabbage, spinach?
This medication will be administered when intravenous fluids are ineffective in treating hypotension.
What are vasopressors/vasoconstrictors?
These findings in a client after a MVA would lead the nurse to prepare for a chest tube insertion.
What is shortness of breath and tracheal deviation?