Patient Data

Exhibits

Each row and each column must have at least one, but may have more than one, response option selected.
Intervention: Promotes safety/ Does not promote safety

Place all client belongings out of reach

Instruct the client to call before getting up

Initiate use of the bed alarm

Complete a swallow study before giving anything by mouth

Place the client in a room near the elevator

Provide a call button kept within reach

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

A.   placing all client belongings out of reach (A) does not promote safety as it may lead the client to attempt to get up unassisted to retrieve their items, increasing the risk of falls.
B.   Instructing the client to call before getting up ensures that assistance is provided, preventing falls due to potential weakness or balance issues.
C.   Initiating the use of a bed alarm helps in monitoring the client's movements, which is crucial in preventing falls, especially when the client might have impaired mobility.
D.   Completing a swallow study before giving anything by mouth is essential to assess the risk of aspiration, which can be heightened due to possible swallowing difficulties post- stroke.
E.   Placing the client in a room near the elevator does not directly promote safety; it could be beneficial for logistical reasons but does not address the client's immediate safety needs.
F.   Providing a call button within reach allows the client to alert staff promptly if they need assistance, thus reducing the risk of injury.

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Correct Answer is C

Explanation

A. Raising the head of the bed can help improve lung expansion and reduce aspiration risk, which is beneficial for a client with pneumonia. However, while this intervention supports respiratory function, it does not directly address the systemic perfusion and organ failure risks associated with septic shock. Therefore, it is not the highest priority intervention in a sepsis protocol.
B. Blood glucose monitoring is important in sepsis because stress-induced hyperglycemia is common and uncontrolled glucose can worsen outcomes. However, this intervention is supportive rather than critical in the early management of septic shock and does not take priority over interventions that directly evaluate perfusion and organ function.
C. Strict intake and output monitoring is essential in septic shock because it provides immediate information about renal perfusion and fluid balance. Septic shock causes widespread vasodilation and capillary leak, leading to decreased organ perfusion and acute kidney injury. Urine output is a key indicator of organ function and response to fluid resuscitation, making this intervention a core component of sepsis management.
D. Assessing extremity warmth helps evaluate peripheral perfusion and can indicate early versus late septic shock. While this is a useful assessment, it is less critical than objective measures such as urine output that directly reflect organ perfusion and guide treatment decisions.

Correct Answer is ["22"]

Explanation

To calculate the drip rate for an IV, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). For the prescribed 1 unit of PRBC at 350 mL to be infused over 4 hours with a drop factor of 15 gtt/mL, the calculation would be: (350 mL x 15 gtt/mL) / (4 hours x 60 minutes/hour). This simplifies to (5250 gtt) / (240 min), which equals 21.875 gtt/min. When rounded to the nearest whole number, the nurse should regulate the infusion to 22 gtt/min.

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Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is C

Explanation

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

Correct Answer is ["22"]

Explanation

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

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Patient Data

Exhibits

Each row and each column must have at least one, but may have more than one, response option selected.
Intervention: Promotes safety/ Does not promote safety