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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Keep diabetic medication on schedule as prescribed.

This is the correct answer because maintaining a regular schedule for diabetic medication is crucial for managing blood glucose levels and preventing complications.

B. Limit maximum daily fat intake to 15% of total calories.

While reducing fat intake can be beneficial for overall health, it is not directly related to managing acute blood glucose levels or preventing immediate complications of diabetes.

C. Check blood sugar levels every four to six hours every day.

Frequent monitoring of blood sugar levels is important, but checking every four to six hours may not be necessary for all clients, especially if they are not on insulin or if their diabetes is well-controlled. It depends on individual needs and physician recommendations.

D. Restrict alcoholic beverages to no more than 1-2 per week.

Limiting alcohol intake is good advice for overall health and diabetes management, but it is not the most critical action compared to keeping medications on schedule to prevent complications.

A. Promote healing process. B. Decrease abdominal pain. C. Reduce intestinal activity. D. Control diarrhea episodes. E. None F. None

Correct Answer is C

Explanation

Activity restriction does not directly decrease abdominal pain. Pain management in Crohn’s disease is typically achieved through medications, dietary adjustments, and addressing inflammation.

B. While activity restriction may indirectly help decrease abdominal pain by reducing inflammation and promoting healing, it is not the primary purpose of the restriction.
C.The primary goal of activity restriction in Crohn's disease is to reduce intestinal activity. By limiting physical exertion, the intestines are less stimulated, which can help reduce inflammation and give the digestive system a chance to rest and recover.
D. While activity restriction may help control diarrhea episodes by reducing physical stress on the intestines, the primary purpose is to promote healing and reduce inflammation. Control of diarrhea may be achieved through other interventions such as dietary modifications and
medication management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information reported by the client indicates understanding?

Correct Answer is A

Explanation

Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

Correct Answer is C

Explanation

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