Podcast
Questions and Answers
What is the most immediate action the nurse should take for the client with pneumonia and low blood pressure?
What is the most immediate action the nurse should take for the client with pneumonia and low blood pressure?
- Administer IV fluids bolus (correct)
- Draw 2 sets of blood cultures
- Administer IV antibiotics
- Initiate IV norepinephrine infusion
Which criterion indicates the possible presence of SIRS in a patient?
Which criterion indicates the possible presence of SIRS in a patient?
- Temperature <97.0
- Temperature >100.4 (correct)
- Respirations <12
- White blood cells <4,000
What is the characteristic symptom of sepsis that would prompt immediate medical intervention?
What is the characteristic symptom of sepsis that would prompt immediate medical intervention?
- Acute headache
- Observable skin rash
- Elevated blood glucose levels
- Persistently low blood pressure (correct)
Given the scenario, what is a potential complication that could develop if the nurse does not act quickly?
Given the scenario, what is a potential complication that could develop if the nurse does not act quickly?
What role do blood cultures play in the management of a client with pneumonia?
What role do blood cultures play in the management of a client with pneumonia?
Flashcards
Sepsis
Sepsis
A condition where the body's immune system overreacts to an infection, causing widespread inflammation and organ damage.
SIRS (Systemic Inflammatory Response Syndrome)
SIRS (Systemic Inflammatory Response Syndrome)
A set of clinical criteria used to identify patients who may be at risk of developing sepsis.
SIRS Stage
SIRS Stage
The initial stage of sepsis, characterized by inflammation and physiological changes but without organ dysfunction.
Shock
Shock
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Septic Shock
Septic Shock
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Study Notes
Patient with Pneumonia and Low Blood Pressure
- A patient with pneumonia has a fever and a dangerously low blood pressure (88/58).
- The nurse must prioritize immediate action.
- The first action is to administer an IV fluid bolus.
- This bolus of 30 mL/kg is crucial for rapidly increasing the patient's intravascular fluid volume and restoring tissue perfusion.
- The reason for this is that Septic shock is caused by inflammatory mediators (e.g., cytokines) released in response to infection. This widespread vasodilation and increased capillary permeability have a negative impact on the patient's blood pressure.
- Other important actions should be considered like getting blood cultures and starting antibiotics but they are secondary to immediate fluid resuscitation.
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Description
This quiz focuses on the crucial nursing interventions for a patient presenting with pneumonia and low blood pressure. Key actions include administering IV fluid bolus to combat septic shock. Understand the importance of fluid resuscitation in restoring tissue perfusion and consider other secondary interventions.
