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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