what is the primary intervention for sepsis
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Nursing Elites

ATI LPN

ATI Comprehensive Predictor PN

1. What is the primary intervention for sepsis?

Correct answer: D

Rationale: The primary intervention for sepsis involves a multifaceted approach, including administering IV antibiotics to address the underlying infection and administering fluids to stabilize the patient's hemodynamic status. Monitoring blood pressure is important in the management of sepsis, but it is not the sole primary intervention. Therefore, the correct answer is 'All of the above' as it encompasses the comprehensive approach required for effective sepsis management.

2. A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.

3. How should a healthcare provider care for a patient with a nasogastric (NG) tube?

Correct answer: A

Rationale: When caring for a patient with a nasogastric (NG) tube, it is crucial to check the tube placement and assess for signs of aspiration. This ensures that the tube is correctly positioned and that the patient is not at risk of complications such as aspiration pneumonia. Choice B is incorrect as flushing the tube with water regularly is not a standard practice and may not be appropriate for all patients. Choice C is incorrect as monitoring for bowel sounds is not directly related to NG tube care, and administering medications is not the primary focus of caring for the tube itself. Choice D is incorrect because administering medications through the NG tube is a specific action that may be taken based on a healthcare provider's order, not a general care guideline for the NG tube.

4. A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: Place the client in a 30-degree lateral position. Positioning the client laterally reduces pressure on bony prominences, improving circulation and helping prevent pressure injuries. Placing the client in a prone position (choice A) increases pressure on the bony prominences, raising the risk of pressure injuries. Similarly, placing the client in a high Fowler's position (choice D) can also increase pressure on certain areas. While encouraging the client to reposition every 4 hours (choice C) is important, the specific lateral positioning is more beneficial in preventing pressure injuries.

5. Which intervention is most important for a client with rheumatoid arthritis?

Correct answer: D

Rationale: The most important intervention for a client with rheumatoid arthritis is to assist with heat application and range of motion exercises. Heat application helps reduce stiffness and improve joint flexibility, while range of motion exercises help maintain mobility and prevent contractures. Massaging inflamed joints with creams and oils may provide temporary relief but does not address the root cause of stiffness and limited mobility in rheumatoid arthritis. Providing support to flexed joints with pillows and pads can be helpful for comfort but does not actively promote mobility. Positioning the client on their abdomen several times a day is not a standard intervention for managing rheumatoid arthritis.

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