A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.
Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Choice A rationale:

Temperature control for either hypothermia or hyperthermia is crucial in septic shock management. Here's a detailed explanation:

Hypothermia:

Mechanism: Septic shock often causes impaired thermoregulation, leading to hypothermia. It can worsen shock by decreasing cardiac output, impairing coagulation, and promoting vasoconstriction.

Intervention: Active warming measures are essential, including: External warming devices (e.g., blankets, forced air warmers) Intravenous fluids warmed to 39-42°C

Warmed humidified oxygen

Minimizing exposure and covering the patient Hyperthermia:

Mechanism: Sepsis can trigger an excessive inflammatory response, leading to hyperthermia. It can exacerbate tissue injury, increase metabolic demands, and worsen organ dysfunction.

Intervention: Aggressive measures to lower temperature are necessary, including:

Antipyretic medications (e.g., acetaminophen, ibuprofen) External cooling methods (e.g., cooling blankets, ice packs) Sedation if shivering occurs

Choice B rationale:

Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine is often required in septic shock to: Improve cardiac output: These agents increase myocardial contractility and heart rate, enhancing blood flow to vital organs.

Maintain blood pressure: They support vasoconstriction, counteracting the widespread vasodilation characteristic of septic shock.

Improve tissue perfusion: By optimizing cardiac output and blood pressure, they help ensure adequate oxygen and nutrient delivery to tissues.

Choice E rationale:

Blood cultures from all suspected sources before administration of antibiotics are essential for guiding appropriate antibiotic therapy.

Early identification of the causative organism: This information is crucial for selecting the most effective antibiotic regimen.

Prevention of antibiotic resistance: Judicious use of antibiotics based on culture results helps prevent the development of antibiotic-resistant bacteria.

Choice F rationale:

Vigorous intravenous fluid resuscitation with 0.9% sodium chloride is a cornerstone of septic shock management.

Replenishing intravascular volume: Septic shock often causes profound intravascular volume depletion due to capillary leak and vasodilation. Fluid resuscitation aims to restore circulating volume and maintain organ perfusion.

Improving hemodynamic stability: By increasing preload and cardiac output, fluids help stabilize blood pressure and support vital organ function.

Choice A rationale:

Removing the tube immediately upon patient gagging is not the most appropriate first step. Gagging is a common reflex during nasogastric tube insertion and can often be managed without removing the tube.

Premature removal could lead to unnecessary discomfort for the patient and potential delays in treatment.

The nurse should attempt to reposition the tube or have the patient sip water to facilitate passage before considering removal.

Choice B rationale:

Tucking the chin to the chest and swallowing are essential maneuvers that help guide the tube into the esophagus and reduce the risk of misplacement into the trachea.

These actions close off the airway and open the esophagus, creating a smoother path for the tube.

The nurse should instruct the patient to perform these actions during insertion to promote successful placement.

Choice C rationale:

While a supine position is often used for nasogastric tube insertion, it is not the most crucial factor for success.

Studies have shown that a high-Fowler's position (sitting upright with head elevated) may be equally effective and potentially more comfortable for patients.

The nurse should consider patient comfort and potential contraindications (such as respiratory distress) when choosing the most appropriate position.

Choice D rationale:

Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement. The correct measurement is from the nose tip to the earlobe to the xiphoid process (NEX).

This landmark-based method provides a more reliable estimation of the distance to the stomach.