how should a nurse assess a patient with sepsis
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. How should a healthcare provider assess a patient with sepsis?

Correct answer: A

Rationale: In sepsis, it is crucial to monitor vital signs to assess the patient's condition and administer fluids to maintain circulation. This approach helps in stabilizing blood pressure and perfusion. While monitoring for fever and administering antibiotics (choice B) is important in managing sepsis, the initial priority lies in assessing and stabilizing the patient's hemodynamic status. Checking for tachycardia and elevated white blood cell count (choice C) can be part of the assessment but does not encompass the immediate intervention needed in sepsis. Administering fluids and providing nutritional support (choice D) are essential in managing sepsis, but the primary step should be to assess the patient's condition through vital sign monitoring.

2. What are the risk factors for the development of pressure ulcers, and how can they be prevented?

Correct answer: A

Rationale: The correct answer is A: Immobility and poor nutrition are significant risk factors for pressure ulcers. Immobility leads to prolonged pressure on certain body areas, increasing the risk of tissue damage. Poor nutrition can impair skin integrity and the body's ability to heal. Prevention strategies include frequent turning and repositioning to relieve pressure points. Choice B is incorrect because increased mobility actually reduces the risk of pressure ulcers. Choice C is incorrect as excess moisture can contribute to skin breakdown, but it is not a primary risk factor. Choice D is incorrect as frequent turning and repositioning are part of the prevention measures, not risk factors.

3. What are the complications of untreated DVT?

Correct answer: A

Rationale: The correct answer is A: Pulmonary embolism and stroke. Untreated DVT can result in these serious complications, emphasizing the importance of timely intervention. Choices B, C, and D are incorrect because they do not represent common complications associated with untreated deep vein thrombosis. Infection and kidney failure, hypertension and vision loss, as well as dehydration and electrolyte imbalance are not typically direct consequences of untreated DVT.

4. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

5. What is the first nursing action when caring for a client with a wound infection?

Correct answer: B

Rationale: The first nursing action when caring for a client with a wound infection is to perform a wound culture before applying antibiotics. This step is crucial to identify the specific infecting organism and determine the most effective antibiotic therapy. Choices A, C, and D are incorrect because changing the dressing, cleansing the wound, or applying a wet-to-dry dressing should only be done after obtaining the culture results and starting appropriate antibiotic treatment.

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