ATI RN
ATI Nur211 Capstone Questions
Extract:
Medical History
Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.
Nurses' Notes
Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glascow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even, unlabored and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous members are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted.
Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.
Client's family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with last dose taken this am. Also states that the client took two aspirin yesterday for a headache.
Vital Signs
Temperature 38.5° C (101.3° F)
Pulse 110/min
Blood pressure 98/60 mm Hg Respiratory rate 26/min
Oxygen saturation 93% on 2 L nasal cannula
Diagnostic Results
RBC count 5.0 (Male 4.7 to 6.1)
WBC count 9,500 mm (5,000 to 10,000/mm3) Platelets 97,000/mm3 (150,000 to 400,000/mm3) Hemoglobin 15 g/dL (Male 14 to 18 g/dL)
Hematocrit 45% (Male 42% to 52% ; Female 37% to 47%)
Glucose 186 mg/dL (74 to 106 g/dL)
Question 1 of 5
A nurse is caring for a 73-year-old client in the emergency department (ED). It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.
Correct Answer: A,B,C,G,H
Rationale:
Correct
Answer: A, B, C, G
Rationale:
A: Obtaining blood cultures helps identify the causative organism for targeted antibiotic therapy.
B: Administering broad-spectrum antibiotics promptly targets potential pathogens, reducing the risk of septic shock.
C: Rapidly administering normal saline helps restore perfusion and improve hemodynamics in sepsis.
G: Measuring lactate levels aids in assessing tissue perfusion and is a key indicator of sepsis severity.
Summary of Incorrect
Choices:
D: Inserting an NG tube is not a priority in managing sepsis in the first hour.
E: Type and cross-matching for packed RBCs is not an immediate intervention for sepsis management.
F: Obtaining a urine specimen is not as crucial as the other actions in the first hour of managing sepsis.
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Question 2 of 5
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Question 4 of 5
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Question 5 of 5
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