Report worsening signs of sepsis such as fever, hypotension, tachycardia, and altered mental status.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A client is being evaluated for sepsis. Which intervention does the nurse anticipate completing before the first dose of antibiotics is given?
Answer: A. Blood cultures should be obtained before antibiotics are started so the causative organism can be identified without being suppressed by the drug. Antibiotics should still be given promptly (within the first hour), but cultures are drawn first whenever it does not significantly delay therapy.
Question 2 of 5
A nurse is caring for a client with a chest tube. The drainage tubing becomes disconnected from the collection device. What is the nurse's priority action?
Answer: B. If the chest tube disconnects from the drainage system, the nurse immediately submerges the end of the tube about 2 cm under sterile water or saline to reestablish a water seal and prevent air from entering the pleural space. Clamping is generally avoided because it can cause a tension pneumothorax.
Question 3 of 5
Within what time frame must a unit of blood be started after it is released from the blood bank, and over what maximum time should one unit infuse?
Answer: A. Blood must be started within 30 minutes of release from the blood bank to avoid bacterial growth from warming, and a single unit should infuse within 4 hours for the same reason. Units left out too long must be returned.
Question 4 of 5
A client receiving a blood transfusion suddenly reports chills, low back pain, and dark urine. What is the nurse's first action?
Answer: B. These signs suggest an acute hemolytic transfusion reaction. The immediate priority is to stop the transfusion at once to prevent further infusion of incompatible blood, then keep the IV line open with normal saline using new tubing and notify the provider and blood bank. Slowing the rate, giving antipyretics, or assessing first would delay stopping a life-threatening reaction.
Question 5 of 5
Before administering a blood transfusion, two nurses must verify:
Answer: B. Two qualified staff verify the client's identity (two identifiers) against the blood bank label, the blood type/Rh, the unit number, and the expiration — at the bedside — to prevent a fatal incompatible transfusion.
Keep the streak going with more questions like these, each with a full rationale.
What is blood culture collection?
Strict aseptic technique is essential to avoid contamination and false-positive results. Memory aid: cultures BEFORE antibiotics, two sites, scrub the site and the bottle tops.
Key points to remember
- Blood cultures should be drawn before antibiotics are started whenever possible to capture the organism.
- At least two sets are typically collected from two separate venipuncture sites to distinguish true infection from contamination.
- Meticulous skin antisepsis and disinfection of the bottle tops prevent contamination and false positives.
- The aerobic and anaerobic bottles are filled with the correct blood volume for accurate results.
- Specimens are sent to the lab promptly and labeled with site and time.
- Cultures drawn through an existing line are more prone to contamination than fresh peripheral sticks.
Nursing priorities
- Collect cultures before the first dose of antibiotics whenever feasible.
- Perform thorough hand hygiene and scrub the venipuncture site and bottle tops with antiseptic.
- Draw the required number of sets from separate sites with adequate blood volume per bottle.
- Label each specimen with site, date, and time and transport to the lab promptly.
- Coordinate timing so antibiotics are not delayed unnecessarily in a septic patient.
Labs & values
Patient teaching
- Blood will be drawn from two different spots to make sure the results are accurate.
- We collect these samples before starting antibiotics whenever possible.
- Tell the nurse if you feel chills, fever, or worsening symptoms.
- Results take time because the lab must grow any bacteria present.
Red flags: report now
- Report worsening signs of sepsis such as fever, hypotension, tachycardia, and altered mental status.
- Never delay life-saving antibiotics in a deteriorating septic patient if cultures cannot be obtained quickly.
- Report suspected specimen contamination or breaks in sterile technique.
- Report a positive culture result to the provider immediately for antibiotic adjustment.
References
Clinical references for this topic
