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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While altered taste sensation can occur with radiation treatment, it’s not the most likely reason for an imbalance in nutritional intake in this scenario.
Choice B rationale
Fatigue can be a side effect of radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.
Choice C rationale
Pain during eating is the most likely cause of imbalanced nutritional intake in this scenario. The patient’s laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the patient from eating, leading to decreased nutritional intake.
Choice D rationale
Nausea can occur with radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.
Correct Answer is B
Explanation
Choice A rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.
Choice B rationale
Neutrophil count is a measure of the number of neutrophils, a type of white blood cell, in the blood. An elevated neutrophil count can indicate an infection, making it the most relevant lab value to check in this scenario.
Choice C rationale
Platelet count is a measure of the number of platelets in the blood. While platelets play a crucial role in blood clotting, they are not directly related to infection and therefore not the most relevant lab value to check in this scenario.
Choice D rationale
Serum sodium level is a measure of the amount of sodium in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.
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