The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Monitor blood glucose level.

Maintain strict intake and output.

Assess warmth of extremities.

Keep head of bed raised 45 degrees.

Answer and Explanation

The Correct Answer is B

Rationale

A. Monitoring blood glucose levels is important, especially in critically ill patients, as hyperglycemia can worsen outcomes in septic shock. However, it is not the most critical intervention in the immediate management of septic shock.

B. Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

C. Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

D. Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

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Correct Answer is A

Explanation

Rationale

A. Monitoring intake and output closely is essential to assess fluid balance and ensure adequate hydration. Replacing fluids intravenously based on this assessment helps maintain hemodynamic stability and prevent dehydration, electrolyte imbalances, and hypovolemia.

B. After surgery for fistula repair, it is important to monitor wound drainage to assess for complications such as infection or delayed healing. Excessive drainage may indicate issues with wound healing or ongoing inflammation, requiring timely intervention.

C. Turning the client every 2 hours helps prevent complications such as pressure ulcers and respiratory complications. It promotes circulation, prevents skin breakdown, and aids in lung expansion. However, while important, this intervention is more focused on preventing physical complications rather than directly addressing the client's immediate medical needs post-surgery.

D. Clients with inflammatory bowel disease, especially those undergoing surgery and critically ill, are at increased risk for skin breakdown due to factors such as decreased mobility, medication effects, and overall health status. Regular skin assessments help detect early signs of breakdown and allow for prompt intervention to prevent pressure ulcers or skin complications.

A. Respiratory rate. B. Pain scale. C. Blood pressure. D. Level of consciousness.

Correct Answer is B

Explanation

Rationale

A. Respiratory rate is important because opioid-induced respiratory depression is a significant concern with hydromorphone. Assessing the respiratory rate helps the nurse detect early signs of respiratory depression.

B. Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.

C. Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.

D. Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.

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The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

Correct Answer is B

Explanation

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