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.
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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Related Questions
Correct Answer is D
Explanation
A. Bruising of the skin is not typically associated with acute gastritis caused by contaminated water. While bruising may be a sign of other medical conditions or complications, it is not directly related to gastritis.
B. Low-grade fever can be a symptom of gastritis, especially if it is caused by an infectious agent. However, it is not typically a severe or emergent symptom that requires immediate reporting unless it is accompanied by other concerning symptoms.
C. Abdominal cramping is a common symptom of gastritis and may occur due to inflammation of the stomach lining. While it should be monitored, it is not as concerning as the potential complication indicated by option D.
D. Bloody emesis (vomiting blood) is a serious symptom that can indicate severe gastritis or complications such as gastrointestinal bleeding. It is essential to report this symptom promptly as it may require immediate medical attention and intervention.
Correct Answer is A
Explanation
A. Administer oxygen via face mask. The decrease in fetal heart rate after contractions indicates possible fetal distress. Administering oxygen to the mother can increase oxygen delivery to the fetus, potentially improving fetal oxygenation and alleviating distress.
B. Apply an Internal fetal heart monitor. While continuous monitoring is important, the first priority is to address the immediate fetal distress. Monitoring alone will not address the issue.
C. Notify the healthcare provider. Notifying the provider is important, but addressing the immediate fetal distress takes priority.
D. Use a vibroacoustic stimulator. Vibroacoustic stimulation can be used to assess fetal well- being, but it does not address the underlying fetal distress, which is the priority.
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