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 D

Explanation

A. Vegetarian lasagna with cheese and spinach, tossed green salad with ranch dressing, and fresh fruit. This meal option contains carbohydrates from the lasagna, salad dressing, and fruit, which can raise blood glucose levels.
B. Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake.

This meal option contains carbohydrates from the bun and angel food cake, which can raise blood glucose levels.
C. Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie. This meal option contains significant amounts of carbohydrates from mashed potatoes and apple pie, which can raise blood glucose levels.
D. Grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine.

This meal option is lower in carbohydrates and contains healthier choices for a client with diabetes, helping to control blood glucose levels more effectively.

A. Lymphangitis. B. Malignancy. C. Viral Infection. D. Bacterial Infection.

Correct Answer is B

Explanation

A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.

B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.

C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.

D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.

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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

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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