A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.
The healthcare provider has prescribed a sepsis protocol to be initiated.
Which intervention should the nurse prioritize in the plan of care?

Keep the head of the bed raised 45 degrees.

Assess the warmth of the extremities.

Maintain strict intake and output records.

Monitor the patient’s blood glucose level.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Keeping the head of the bed raised 45 degrees is a common practice in intensive care units to prevent aspiration pneumonia. However, in the context of septic shock, this intervention is not the highest priority.

Choice B rationale

Assessing the warmth of the extremities can provide information about peripheral perfusion. Cold extremities may indicate poor perfusion, a common symptom in septic shock. However, this is not the most critical intervention in the management of septic shock.

Choice C rationale

Maintaining strict intake and output records is crucial in the management of septic shock. Fluid balance is a key component of sepsis management. Monitoring fluid balance helps ensure that the patient is adequately hydrated, which is essential for maintaining blood pressure and organ perfusion.

Choice D rationale

Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or has a history of diabetes. However, in the context of septic shock, this is not the highest priority.

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Correct Answer is A

Explanation

Choice A rationale

Instructing the patient that it is important to reduce the dose of the medication gradually is the best course of action. Temazepam is a benzodiazepine, and abrupt discontinuation can lead to withdrawal symptoms, which can be severe and include seizures. Therefore, it’s crucial to taper off the medication under the supervision of a healthcare provider.

Choice B rationale

Advising the patient to stop taking the medication immediately is not recommended due to the risk of withdrawal symptoms.

Choice C rationale

Encouraging the patient to obtain a prescription for a benzodiazepine antagonist is not typically the first line of action when discontinuing temazepam.

Choice D rationale

Discussing with the patient that there may be a need for additional sleep if the feeling of fatigue is present the next day is not directly addressing the issue. The patient’s feelings of being “hungover” are likely due to the effects of the medication, not a lack of sleep.

A. Print the electronic medical record (EMR) from the backup server. B. Wait for notification that the system has been rebooted. C. Identify information as a late entry in the record. D. Notify the information services department of the situation.

Correct Answer is D

Explanation

Choice A rationale

Printing the electronic medical record (EMR) from the backup server may not be the most immediate action required. While having a backup of the EMR is important, it does not address the immediate issue of the system failure.

Choice B rationale

Waiting for notification that the system has been rebooted is a passive approach and may not be the most effective initial action. It does not address the immediate need to communicate the issue to the appropriate department.

Choice C rationale

Identifying information as a late entry in the record is a documentation practice that is used when charting is not completed in a timely manner. However, this action does not address the immediate issue of the system failure.

Choice D rationale

Notifying the information services department of the situation is the correct action. This allows the appropriate department to begin troubleshooting and resolving the issue. In the event of a system failure, the first step should be to report the issue so that it can be addressed as quickly as possible.

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A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.The healthcare provider has prescribed a sepsis protocol to be initiated.Which intervention should the nurse prioritize in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient taking temazepam informs you, the nurse, of plans to quit taking the medication due to feelings of being “hungover” the next day.What action should you implement?

Correct Answer is A

Explanation

After a scheduled downtime, the computer documentation system fails to restart.What should be the nurse’s initial action?

Correct Answer is D

Explanation

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A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.
The healthcare provider has prescribed a sepsis protocol to be initiated.
Which intervention should the nurse prioritize in the plan of care?