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. Increased hydrostatic pressure in the portal vein B. Decreased oncotic pressure in the plasma C. Increased aldosterone secretion by the adrenal glands D. All of the above

Correct Answer is D

Explanation

Choice A reason:

Increased hydrostatic pressure in the portal vein is one factor that causes ascites. The portal vein carries blood from the digestive organs to the liver for processing. However, when the liver is damaged by alcohol abuse, it becomes scarred and fibrotic, creating resistance to blood flow. This results in increased pressure in the portal vein and its branches, which forces fluid out of the capillaries into the abdominal cavity.

Choice B reason:

Decreased oncotic pressure in the plasma is another factor that causes ascites. Oncotic pressure is the force exerted by proteins in the plasma that attracts fluid into the capillaries from the interstitial space. However, when the liver is damaged by alcohol abuse, it cannot produce enough proteins, such as albumin and globulin, which are essential for maintaining oncotic pressure. This results in decreased oncotic pressure in the plasma and increased fluid movement into the interstitial space and the abdominal cavity.

Choice C reason:

Increased aldosterone secretion by the adrenal glands is another factor that causes ascites. Aldosterone is a hormone that regulates the balance of sodium and water in the body. It acts on the kidneys to increase the reabsorption of sodium and water from the urine into the blood. However, when the liver is damaged by alcohol abuse, it cannot metabolize aldosterone properly, leading to its accumulation in the blood. This results in increased sodium and water retention in the body and increased fluid movement into the interstitial space and the abdominal cavity.

Choice D reason:

Ascites is caused by a combination of factors that affect the fluid balance in the abdominal cavity.

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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

A nurse is caring for a client who has liver failure due to alcohol abuse. The nurse observes that the client has ascites, which is an accumulation of fluid in the abdominal cavity. The nurse understands that this condition is caused by:

Correct Answer is D

Explanation

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