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    HESI RN EXIT 1 PROCTORED EXAM

    An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postburn infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?

    Explanation & Rationale

    A. Provide bedside equipment for transmission and protective precautions: While infection control precautions are important, obtaining cultures to identify the source of infection and guide treatment is the priority in this scenario. B. Evaluate daily serum electrolytes and hydration status: While monitoring electrolytes and hydration is important in critically ill patients, it is not the priority in this situation where the client is presenting with signs of systemic infection. C. Culture sputum, urine, burn wound, and all intravenous access sites: The priority is to obtain cultures to identify the source of infection, which will guide antibiotic therapy and other interventions. D. Implement central line-associated bloodstream infection: While preventing central line- associated bloodstream infection is important, it is not the priority in this situation where the client is presenting with signs of systemic infection.

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