A patient who is in hypovolemic shock has the following clinical signs: BP 80/55 mmHg, heart rate 120 beats/min, and urine output of 20 mL/hr. After administering an IV fluid bolus, which of these signs is the best indication of improved perfusion?

Choice A reason: Finger-stick glucose is important for monitoring blood sugar levels, especially in septic patients who may develop hyperglycemia. However, it is not the highest priority compared to obtaining blood cultures and administering antibiotics.

Choice B reason: Obtaining blood cultures x2 is the first priority in managing a patient with sepsis. Identifying the causative organism and determining antibiotic susceptibility is crucial for guiding effective treatment. Blood cultures should be obtained before administering antibiotics to ensure accurate results.

Choice C reason: Tylenol (acetaminophen) 650 mg PO may be given to reduce fever and provide comfort, but it is not the highest priority in the initial management of sepsis. Immediate diagnostic and therapeutic interventions are more critical.

Choice D reason: Vancomycin 760 mg IV is an important antibiotic for treating sepsis, especially if a resistant organism is suspected. However, it should be administered after blood cultures are obtained to avoid contaminating the cultures and ensuring accurate identification of the causative organism.

Choice A reason: Encouraging the patient to continue an exercise routine such as weightlifting is not appropriate for a patient with esophageal varices. Weightlifting and other strenuous activities can increase intra-abdominal pressure, which may lead to the rupture of the varices and cause severe bleeding.

Choice B reason: Advising the patient to avoid straining at stools is the correct intervention. Straining during bowel movements can increase intra-abdominal pressure and the risk of rupturing the esophageal varices. The nurse should encourage the patient to maintain soft stools through a high-fiber diet, adequate hydration, and possibly stool softeners to prevent straining.

Choice C reason: Providing hot liquids as desired is not recommended for patients with esophageal varices. Hot liquids can cause vasodilation and potentially increase the risk of bleeding from the varices. Patients should be advised to consume beverages at moderate temperatures.

Choice D reason: Advising the patient to limit themselves to one alcoholic drink per day is not appropriate. Alcohol consumption can worsen liver disease, increase portal hypertension, and exacerbate esophageal varices. Patients with esophageal varices should be advised to avoid alcohol completely to reduce the risk of complications.