After Receiving a Handoff Report from the Night Shift,the Nurse

question 1

Multiple Choice

After receiving a handoff report from the night shift,the nurse completes the morning assessment of a patient with severe sepsis.Vital sign assessment notes blood pressure 95/60 mm Hg,heart rate 110 beats/min,respirations 32 breaths/min,oxygen saturation ( SpO₂ ) 96% on 45% oxygen via Venturi mask,temperature 101.5° F,central venous pressure ( CVP/RAP ) 2 mm Hg,and urine output of 10 mL for the past hour.The nurse initiates which active physician order first?

• A) Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg.
• B) Increase supplemental oxygen therapy to maintain SpO₂ greater than 94%.
• C) Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr.
• D) Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101°F.

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Definitions:

Expiratory Reserve Volume

The additional amount of air that can be forcibly exhaled after the completion of a normal, quiet expiration.

Warmer

An adjective describing an increase in temperature or a device used to raise the temperature of something.

Moisture

The presence of a liquid, especially water, often in trace amounts in the environment or substances.

Food Passage

The process by which food moves through the digestive tract, starting from ingestion into the mouth and continuing through the esophagus, stomach, and intestines until waste is excreted.