Question

A client has the following vital signs: temperature 101.4 degrees F, blood pressure 88/54, pulse 128 beats/minute, and respirations 34 breaths/minute. Physician orders are shown in the accompanying chart. The nurse first intervenes by

a) Increasing DRLR to the prescribed rate
b) Providing acetaminophen for the elevated temperature
c) Obtaining the blood cultures
d) Administering the Vancomycin

Answer 1

The nurse should initially prioritize interventions to stabilize the patient's hemodynamic status. Hence, obtaining blood cultures should be the first action due to the signs of potential septic shock, followed by fever management and fluid support.

Step-by-step explanation:

The vital signs provided for the client indicate a state of potential septic shock, characterized by fever, hypotension (low blood pressure), tachycardia (increased heart rate), and tachypnea (increased breathing rate). These signs suggest that the body is fighting a severe infection. In this clinical scenario, the nurse's first intervention should focus on addressing the most critical and life-threatening changes in vital signs that could lead to rapid clinical deterioration.

Considering these vital signs and the potential for septic shock, the nurse should initially prioritize interventions aimed at stabilizing the patient's hemodynamic status. In this case, the first intervention would be to obtain the blood cultures. This is essential to identify the infecting organism before starting or altering antibiotic therapy because it helps in determining the most effective antibiotic, especially in the event of drug-resistant infections. After blood cultures are obtained, management of the fever with acetaminophen and addressing the hypotension by increasing the fluid rate, if prescribed, would follow. Administering vancomycin without obtaining blood cultures could alter the results of the cultures and delay appropriate treatment.