Author Question: After change-of-shift report in the progressive care unit, who should the nurse care for first? ... (Read 104 times)

joe · **on:** Jun 25, 2018

After change-of-shift report in the progressive care unit, who should the nurse care for first?

a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases
b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics
c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute
d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

Question 2

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider?

a. Temperature and IV site appearance
b. Oxygen saturation and breath sounds
c. Platelet count and presence of petechiae
d. Blood pressure, pulse rate, respiratory rate.

princessflame2016 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
Antibiotics should be administered within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS) and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.

Answer to Question 2

ANS: C
The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome (MODS) is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.