A nurse is caring for a client with peritonitis who developed sepsis. Which nursing intervention is the highest priority in managing this complication?
Administering pain medication as prescribed
Monitoring vital signs every 4 hours
Initiating broad-spectrum antibiotic therapy
Providing deep breathing exercises
The Correct Answer is C
Choice A reason:
Administering pain medication is important for the client's comfort, but it is not the highest priority in managing sepsis, a life-threatening complication of peritonitis. Addressing the underlying infection with antibiotics takes precedence.
Choice B reason:
Monitoring vital signs is essential for assessing the client's condition, but initiating broad-spectrum antibiotic therapy is more critical in managing sepsis.
Choice C reason:
Initiating broad-spectrum antibiotic therapy is the highest priority in managing sepsis. Prompt administration of antibiotics is crucial to treat the bacterial infection and prevent its spread.
Choice D reason:
Providing deep breathing exercises is important for preventing respiratory complications, but it is not the highest priority compared to addressing sepsis with antibiotics.
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Correct Answer is B
Explanation
Choice A reason:
Changing the IV site every 24 hours is not necessary for IV antibiotic administration unless there is an indication of infiltration or infection at the site.
Choice B reason:
Administering the antibiotics using an infusion pump is essential to ensure accurate and controlled delivery of the medication, particularly when the client's condition requires a precise dosing schedule.
Choice C reason:
Discontinuing the antibiotics after 48 hours of improvement may lead to a recurrence of the infection. Clients with peritonitis often require a full course of antibiotic therapy to ensure complete eradication of the infection.
Choice D reason:
Administering the antibiotics through a peripheral IV catheter may not be suitable for the client's condition, as peritonitis may necessitate the use of a central line for administration of IV medications.
Correct Answer is C
Explanation
Choice A reason:
Anxiety may lead to restlessness, but the assumption of a fetal position suggests a pain response, which is a common finding in peritonitis.
Choice B reason:
Fatigue may lead to restlessness, but it does not explain the assumption of a fetal position, which is a pain-coping mechanism.
Choice C reason:
The client assuming a fetal position and exhibiting restlessness are indicative of pain, which is a common symptom in peritonitis.
Choice D reason:
Respiratory distress is not directly related to the findings described in the scenario.
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