A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Monitor blood glucose level.

Maintain strict intake and output.

Keep head of bed raised 45 degrees.

Assess warmth of extremities.

Answer and Explanation

The Correct Answer is B

Rationale for A: Monitoring blood glucose levels is important in septic patients as hyperglycemia can occur due to stress response, and insulin resistance may develop. However, it is not the most critical intervention for immediate stabilization.
Rationale for B: Maintaining strict intake and output is crucial for a patient in septic shock because fluid balance is a key component in managing shock. Accurate measurement of intake and output ensures appropriate fluid resuscitation, which is vital for maintaining blood pressure and organ perfusion.
Rationale for C: Keeping the head of the bed raised 45 degrees can help prevent aspiration, which is particularly important in patients who are at risk of gastrointestinal bleeding or those who are sedated. However, this is not the primary intervention for septic shock management.
Rationale for D: Assessing the warmth of extremities can provide information about peripheral circulation and may indicate the effectiveness of cardiac output. Nevertheless, it is not the most immediate concern in the management of septic shock.

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Correct Answer is A

Explanation

Rationale for A: Redressing the abdominal incision is crucial as the dressing is no longer occlusive, which could lead to infection. An intact dressing also prevents the client from picking at the site, which could cause further harm or delay healing.
Rationale for B: Leaving the lights on might help with visual perception for a client with dementia, but it does not directly address the immediate risk of infection or the client's interference with the dressing.
Rationale for C: Applying restraints could be considered for a client who is at risk of harming themselves, but this should be a last resort after other interventions have been tried due to the potential for physical and psychological harm.
Rationale for D: Replacing the IV site with a smaller gauge is not indicated by the pink insertion site alone and does not address the client's confusion or behavior towards the dressing.

A. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Assign the UAP to provide care for another client and assume full care of the client.

Correct Answer is C

Explanation

A. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. While important, this does not address the immediate issue of appropriate personal protective equipment (PPE).

B. Remind the UAP to apply a fitted respirator mask before entering the client's room. A fitted respirator mask is not necessary for influenza, which typically requires droplet precautions, not airborne precautions.
C. Review the need for the UAP to wear a face mask while in close contact with the client.

Influenza is spread through respiratory droplets, so a face mask is necessary for close contact to prevent transmission.
D. Assign the UAP to provide care for another client and assume full care of the client. This is not necessary if the UAP is appropriately trained and reminded to use the correct PPE.

Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
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A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

Correct Answer is C

Explanation

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A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?