A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care?

Maintain strict intake and output.

Assess warmth of extremities.

Keep head of bed raised 45 degrees.

Monitor blood glucose level.

Answer and Explanation

The Correct Answer is A

Septic shock is a life-threatening condition characterized by a severe infection that leads to systemic inflammation, organ dysfunction, and low blood pressure. Maintaining strict intake and output monitoring is essential to assess the client's fluid balance and response to interventions. It allows the nurse to closely monitor the client's urine output, which is a crucial indicator of renal perfusion and overall organ function.

Monitoring urine output helps the nurse assess the adequacy of tissue perfusion and the client's response to fluid resuscitation. A decrease in urine output can be an early sign of worsening organ dysfunction and a need for further interventions.

While assessing the warmth of extremities is important for evaluating peripheral perfusion, maintaining strict intake and output monitoring takes priority as it provides more comprehensive information about the client's overall fluid status.

Raising the head of the bed 45 degrees (semi-Fowler's position) can help optimize respiratory function and reduce the risk of aspiration, but it is not the most important intervention in this case.

Monitoring blood glucose levels is important, as hyperglycemia can be associated with sepsis. However, in the context of septic shock, maintaining strict intake and output monitoring takes precedence as it directly assesses the client's fluid balance and response to interventions.

It's crucial to note that the management of septic shock requires a multidisciplinary approach, and other interventions, such as administering appropriate antibiotics, initiating fluid resuscitation, and addressing the underlying source of infection, should also be implemented in a timely manner.

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Correct Answer is C

Explanation

Regular exercise is a vital component of managing type 2 diabetes. It helps to lower blood glucose levels, improve insulin sensitivity, and increase HDL (the "good" cholesterol) levels. However, it is important for the client to obtain medical approval before starting or modifying an exercise regimen. The healthcare provider can assess the client's overall health status and provide specific recommendations regarding the type, duration, and intensity of exercise suitable for the client's individual needs and any potential limitations.

Limiting calories on days unable to exercise is a valid strategy for managing weight and blood glucose levels; however, it is not specifically related to increasing HDL levels. It is important to maintain a balanced and healthy diet overall.

Monitoring blood glucose levels daily is an important self-care practice for individuals with diabetes, but it is not specifically focused on increasing HDL levels. Blood glucose monitoring helps to assess the effectiveness of diabetes management and make necessary adjustments to medication, diet, or exercise.

Monthly appointments with the dietitian can be beneficial for diabetes management, as dietary modifications play a significant role. However, the instruction regarding exercise is more directly related to increasing HDL levels, and the frequency of appointments with the dietitian may vary based on individual needs and goals.

A. The amount of time the child was submerged B. Temperature of water C. Whether or not anyone witnessed the fall into the pool D. Oxygen concentration of the ambient air E. The weight of the child

Correct Answer is ["A","C","D"]

Explanation

A) Correct- The duration of submersion is a critical factor in determining the potential level of hypoxemia. Prolonged submersion leads to a higher risk of severe hypoxia and its associated complications.
B) Incorrect- While water temperature can affect the body's response to submersion, it is not directly related to the level of hypoxemia. Hypoxemia primarily results from the lack of oxygen intake during submersion.
C) Correct- Witnessing the fall into the pool is important because immediate initiation of cardiopulmonary resuscitation (CPR) can improve the chances of a positive outcome. Bystander CPR can help maintain oxygenation and circulation until professional help arrives.
D) Correct- The oxygen concentration in the surrounding air is crucial for oxygen delivery to the body's tissues. In cases of submersion, the availability of oxygen in the air the child is breathing plays a role in determining the level of hypoxemia.
E) Incorrect- The weight of the child is not a significant factor in determining the level of hypoxemia during submersion. The primary determinants are factors like submersion duration, availability of oxygen, and prompt initiation of CPR.

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Naxlex Comprehensive Predictor Exams

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

Correct Answer is C

Explanation

Exhibits here Review H and P. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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