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.
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 ["B","D","F"]
Explanation
As people age, the turnover of skin cells decreases, resulting in slower wound healing. This can prolong the healing process and increase the risk of complications.
The immune system's function, including T-cell function, tends to decline with age.
T-cells play a crucial role in the immune response and wound healing. Decreased T-cell function can impair the body's ability to fight infection and promote efficient healing.
With aging, there is a natural loss of subcutaneous fat, which can affect wound healing. Subcutaneous fat provides padding and protection to the underlying tissues, and its reduction can increase the risk of tissue damage and delays in healing.
Insulin resistance, pigmentation changes, and polypharmacy are not directly age-related factors that impact wound healing. Insulin resistance is a condition related to impaired glucose metabolism and can affect wound healing in individuals with diabetes or other metabolic disorders, but it is not necessarily an age-related factor. Pigmentation changes and polypharmacy (the use of multiple medications) may be associated with aging but do not directly affect the physiological processes involved in wound healing.
Correct Answer is ["25"]
Explanation
The prescription is for 1 gram of azithromycin, which is 1000 mg. The concentration of
the suspension is 200 mg per 5 mL. To calculate the amount in mL:
1000 mg / 200 mg per 5 mL = 25 mL
The nurse should administer 25 mL of the suspension.
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