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 ["A","B","C"]
Explanation
Choice A rationale
The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.
Choice B rationale
The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.
Choice C rationale
The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.
Choice D rationale
The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Sending wound drainage for culture and sensitivity is a key step in diagnosing and treating VRE. This can help determine the most effective antibiotic treatment20.
Choice B rationale
There is no specific “low bacteria diet” recommended for VRE infections20.
Choice C rationale
Standard precautions, including wearing a mask, are important for preventing the spread of VRE1617181920.
Choice D rationale
Contact precautions, such as wearing gloves and gowns, are recommended for staff and visitors to prevent the spread of VRE1617181920.
Choice E rationale
Monitoring the client’s white blood cell count can help assess the body’s response to the infection and the effectiveness of treatment20.
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