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RN ATI Advanced MedSurg Exam 3

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1 : A nurse is caring for a 73-year-old client in the emergency department (ED)

Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.

Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glascow coma score is 13 and Modified Early

Warning System (MEWS) score is 6. Respirations are even. unlabored and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous members are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted.

Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.

Client's family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with last dose taken this am. Also states that the client took two aspirin yesterday for a headache.

Temperature 38.50C (1 01.30 F) Pulse 1 10/min

Blood pressure 98/60 mm Hg Respiratory rate 26/min

Oxygen saturation 93% on 2 L nasal cannula

Diagnostic Results

RBC count 5.0 (Male 4.7 to 6.1)

WBC count 9,500 mm3 (5,000 to 10,OOO/mm3) Platelets 97,000/mm3 (1 50,000 to 400,000/mm3) Hemoglobin 1 5 g/dL (Male 14 to 18 g/dL)

Hematocrit (Male to 52%; Female to 47%) Glucose 186 mg/dL (74 to 106 g/dL)

It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

Insert a nasogastric (NG) tube. Type and cross-match for 2 units of packed RBCs. Administer broad-spectrum antibiotics. Measure lactate level. Rapidly administer 30 ml/kg of normal saline. Obtain blood cultures. Obtain a urine specimen. Obtain a wound culture.

Hint : 💥Sepsis bundle: fluids, lactate, cultures, antibiotics.

Correct Highlights :

Administer broad-spectrum antibiotics.
Measure lactate level.
Rapidly administer 30 ml/kg of normal saline.
Obtain a wound culture.

Rationale :

Administering broad-spectrum antibiotics within the first hour is a life-saving priority in sepsis management, as delayed antimicrobial therapy is associated with increased mortality.
Measuring lactate provides an essential marker of tissue hypoxia and guides the resuscitation process. Elevated levels indicate impaired perfusion.
Rapid administration of 30 mL/kg of isotonic crystalloid (such as 0.9% sodium chloride) is the recommended initial fluid resuscitation step for hypotension or lactate ≥4 mmol/L.
Obtaining blood cultures prior to starting antibiotics ensures that the causative organism can be accurately identified and treated appropriately.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 : A nurse is caring for a 73-year-old client in the emergency department (ED)

Correct Highlights :

2 : A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

3 : A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

4 : Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

5 : Mr Jones came to the ER complaining of chest palpitations. He states his heart feels like it is "racing". The nurse found the following rhythm on the monitor. What is the next step would the nurse expect to take first?

6 : A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

7 : A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

8 : Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

9 : The nurse is caring for a client who has heart failure with an EF of 40%. The client has a BP of 170/67 with an HR of 60. He currently is in normal sinus rhythm and has an amber urine output of 45ml in the last 3 hours. Which medication would the nurse expect to give first?

10 : A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first?