A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock.
The healthcare provider prescribes a sepsis protocol.
Which intervention is most important for the nurse to include in the plan of care?
Keep the head of the bed raised 45 degrees.
Monitor the patient’s blood glucose level.
Assess the warmth of the patient’s extremities.
Maintain strict intake and output.
The Correct Answer is D
Choice A rationale
Keeping the head of the bed raised 45 degrees can help improve lung expansion and reduce the risk of aspiration, which is particularly important for patients who are intubated or receiving enteral nutrition. However, it is not the most important intervention for a patient with septic shock.
Choice B rationale
Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or parenteral nutrition, as these can increase blood glucose levels. However, it is not the most important intervention for a patient with septic shock.
Choice C rationale
Assessing the warmth of the patient’s extremities can provide information about peripheral perfusion and may be useful in monitoring the patient’s response to treatment. However, it is not the most important intervention for a patient with septic shock.
Choice D rationale
This is the correct answer. Maintaining strict intake and output is crucial in managing a patient with septic shock. Fluid balance is a key component of managing septic shock, and accurate intake and output measurements are essential for guiding fluid resuscitation and assessing the patient’s response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Reviewing serum protein levels can provide valuable information about a client’s nutritional status and liver function. However, in the context of a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness, and has a high polymorphonuclear leukocyte count in ascitic fluid, initiating antibiotic therapy is the priority.
Choice B rationale
Beginning abdominal girth measurements can be useful for monitoring the progression of ascites in a client with liver disease. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Choice C rationale
Initiating antibiotic therapy is the correct intervention in this case. The client’s symptoms and the high polymorphonuclear leukocyte count in the ascitic fluid suggest spontaneous bacterial peritonitis, a serious complication of cirrhosis that requires immediate antibiotic treatment.
Choice D rationale
Assessing neurological status is important in clients with liver disease, as they are at risk for hepatic encephalopathy. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Correct Answer is A
Explanation
Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.
Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.
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