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 ["C","D","E","F","G","H","J"]
Explanation
Based on the provided information, the following assessment findings require immediate follow-up by the nurse:
- Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
- Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
- Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
- Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
- The client is pale: Paleness can be a sign of decreased oxygenation.
- Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
- Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.
Correct Answer is B
Explanation
Choice A rationale
While social workers can provide support therapy, they are not typically involved in teaching medical procedures like insulin injection15.
Choice B rationale
Leaving the room and returning later can give the client time to process the information and prepare for learning. It’s important to respect the client’s feelings and readiness to learn15.
Choice C rationale
While it’s true that insulin is a life-saving drug for people with type 1 diabetes, simply explaining this may not address the client’s fears or concerns about self-injection15.
Choice D rationale
Encouraging relaxation techniques can be helpful, but it doesn’t directly address the issue of teaching insulin injection15.
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