Author Question: The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis: ... (Read 78 times)

MirandaLo · **on:** Jun 25, 2018

The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2 F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?

a. Give the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol).
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the patient's vital signs.

Question 2

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following medications ordered. Which medication should the nurse discuss with the health care provider before giving?

a. Pantoprazole (Protonix) 40 mg IV
b. Gentamicin (Garamycin) 60 mg IV
c. Sucralfate (Carafate) 1 g per nasogastric tube
d. Methylprednisolone (Solu-Medrol) 60 mg IV

dlook33 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.

Answer to Question 2

ANS: B
Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.