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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
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