1 :

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 :
  1. 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.
  2. Measuring lactate provides an essential marker of tissue hypoxia and guides the resuscitation process. Elevated levels indicate impaired perfusion.
  3. 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.
  4. Obtaining blood cultures prior to starting antibiotics ensures that the causative organism can be accurately identified and treated appropriately.
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2 :

Hint : Monitoring Kidney Function.

Correct Answers:

  • Metformin

Rationale :
Metformin + contrast dye can cause lactic acidosis and kidney damage, especially in patients with renal impairment. It should be held for 48 hours before and after the procedure if kidney function is impaired.
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3 :

Hint : Fibrillation = Fast and Irregular.

Correct Answers:

  • Atrial fibrillation

Rationale :
Atrial fibrillation (AFib) presents with an irregularly irregular pulse and a pulse deficit due to ineffective atrial contractions. Symptoms include palpitations, dizziness, and fatigue due to decreased cardiac output.
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4 :

Hint : No pee ,No norepi.

Correct Answers:

  • The patient has had no urine output since admission.

Rationale :
Norepinephrine is a vasopressor, increasing BP by constricting blood vessels, but if there’s no urine output (anuria), kidney perfusion is already poor. Without adequate fluids, norepinephrine can worsen renal failure.
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5 :

Hint : V for Vagal in SVT.

Correct Answers:

  • Ask him to blow into a syringe

Rationale :
Vagal maneuvers (like bearing down or blowing into a syringe) stimulate the vagus nerve and can slow down SVT. If ineffective, adenosine or synchronized cardioversion is used.
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6 :

Hint : Too much fluid = Trouble breathing.

Correct Answers:

  • Dyspnea

Rationale :
Circulatory overload occurs when too much fluid is given too quickly, leading to pulmonary edema and dyspnea. Other symptoms include hypertension, tachycardia, and crackles in the lungs.
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7 :

Hint : Atrial Fib = Always Irregular.

Correct Answers:

  • Irregular

Rationale :
AFib causes an irregularly irregular pulse due to disorganized electrical activity in the atria. Other symptoms include fatigue, palpitations, and dizziness.
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8 :

Hint : Paralysis ≠ Pain control.

Correct Answers:

  • No sedative is ordered for the patient

Rationale :
Neuromuscular blockers (like Nimbex) paralyze muscles but do not provide sedation or pain relief—patients need sedation and analgesia. Without sedation, the patient may experience awareness while being paralyzed, which is terrifying.
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9 :

Hint : Nitro lowers the pressure, making the heart’s job easier.

Correct Answers:

  • Nitroglycerin Drip

Rationale :
Nitroglycerin reduces afterload and preload, decreasing the heart's workload in hypertensive heart failure. Dopamine or fluids may be needed if BP drops too low
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10 :

Hint : No pressure= Give fluids first

Correct Answers:

  • Insert two large-bore IV catheters.

Rationale :
The client is likely in hypovolemic shock—fluid resuscitation is the priority to restore perfusion. Oxygen and blood transfusions are also important but must follow fluid replacement.
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Total Questions: 10

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