A nurse is assessing a client who has septic shock. The nurse notes that the client has a blood pressure of 80/50 mmHg, a heart rate of 120 beats per minute, a respiratory rate of 28 breaths per minute, and a temperature of 39°C.

The nurse calculates that the client has a Sequential Organ Failure Assessment (SOFA) score of what value?

Provide supplemental oxygen as needed

Answer and Explanation

The Correct Answer is A

The SOFA score is a tool that assesses the degree of organ dysfunction or failure in septic shock. It is based on six parameters: blood pressure, Glasgow coma scale, PaO2/FiO2 ratio, platelet count, bilirubin level, and creatinine level. Each parameter is assigned a score from 0 to 4 based on the severity of the abnormality. The total SOFA score ranges from 0 to 24, with higher scores indicating worse organ dysfunction or failure.

The client's blood pressure of 80/50 mmHg corresponds to a SOFA score of 1, as it indicates hypotension.

The client's Glasgow coma scale is not given, so it is assumed to be normal (15), which corresponds to a SOFA score of 0.

The client's PaO2/FiO2 ratio is not given, so it is assumed to be normal (>400), which corresponds to a SOFA score of 0.

The client's platelet count is not given, so it is assumed to be normal (>150 x 10^9/L), which corresponds to a SOFA score of 0.

The client's bilirubin level is not given, so it is assumed to be normal (<20 micromol/L), which corresponds to a SOFA score of 0.

The client's creatinine level is not given, so it is assumed to be normal (<110 micromol/L), which corresponds to a SOFA score of 0.

The total SOFA score is the sum of the scores for each parameter: 1 + 0 + 0 + 0 + 0 + 0 = 1. Therefore, the client has a SOFA score of 1.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason:

Restricting fluid intake is not an action that the nurse should take for a client who has hypernatremia. Fluid restriction can worsen hypernatremia by increasing the concentration of sodium in the blood. Fluid intake should be increased or replaced with isotonic or hypotonic fluids to dilute sodium and correct hypernatremia.

Choice B reason:

Monitoring neurological status is an action that the nurse should take for a client who has hypernatremia. Hypernatremia can cause neurological symptoms such as confusion, agitation, seizures, coma, and death due to cellular dehydration and brain shrinkage. The nurse should assess the client's level of consciousness, orientation, memory, behavior, and reflexes regularly and report any changes or deterioration.

Choice C reason:

Administering hypotonic IV fluids is an action that the nurse should take for a client who has hypernatremia. Hypotonic fluids have a lower concentration of solutes than normal body fluids and can help lower serum sodium levels by moving water into the cells from the blood vessels. The nurse should administer hypotonic fluids slowly and carefully to avoid fluid overload or cerebral edema.

Choice D reason:

Encouraging foods high in sodium is not an action that the nurse should take for a client who has hypernat

A. Healing of ulcers B. Relief of pain C. Eradication of H. pylori D. Prevention of bleeding E. Reduction of inflammation

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason:

This is a correct answer because healing of ulcers is an expected outcome of PPI therapy for PUD, as it occurs when the acid-induced damage to the mucosa is repaired and the ulcer is closed.

Choice B reason:

This is a correct answer because relief of pain is an expected outcome of PPI therapy for PUD, as it occurs when the acid-induced irritation and inflammation of the mucosa and the nerve endings are reduced.

Choice C reason:

This is an incorrect answer because eradication of H. pylori is not an expected outcome of PPI therapy for PUD, as it requires a combination of antibiotics and bismuth compounds to kill the bacteria and prevent its recurrence.

Choice D reason:

This is a correct answer because prevention of bleeding is an expected outcome of PPI therapy for PUD, as it occurs when the acid-induced erosion and perforation of the mucosa and the blood vessels are prevented.

Choice E reason:

This is a correct answer because reduction of inflammation is an expected outcome of PPI therapy for PUD, as it occurs when the acid-induced activation of inflammatory mediators and immune cells are inhibited.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

Correct Answer is ["A","B","D","E"]

Explanation

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