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. This is because preventing falls and injuries is crucial for individuals with osteoporosis, as their bones are more fragile and susceptible to fractures. Creating a safe environment by identifying and resolving home safety hazards can significantly reduce the risk of falls, which is essential for the well-being of someone with osteoporosis.

B. Constipation can be a concern for older adults, especially those with limited mobility. While addressing constipation is important for overall comfort and well-being, it is not directly related to osteoporosis management.

C. Understanding risk factors for osteoporosis is important for prevention and management but not of immediate concern.

D. Adequate calcium intake helps maintain bone density and reduce the risk of fractures in individuals with osteoporosis. However, this is not a priority.

A. Ask the client's friend to sign the informed consent since the client is unresponsive. B. Notify the unit manager that an emergency court order is needed to allow surgery. C. Carry on with surgical preparation of the client without a signed informed consent. D. Continue to provide life support until a thorough search for a guardian is completed.

Correct Answer is C

Explanation

Rationale

A. The client's friend may not legally be authorized to provide consent unless they hold medical power of attorney or legal guardianship for the client. Without documentation of such authority, the friend cannot sign the informed consent.

B. In emergency situations where a patient lacks decision-making capacity and there is no available legal guardian or next of kin to provide consent, hospitals may seek a court order to proceed with necessary treatment. However, this could delay emergency treatment.

C. This is based on the legal and ethical understanding that saving the patient's life takes precedence when immediate action is required and consent cannot be obtained.

D. Providing life support ensures that the client's immediate medical needs are addressed while efforts are made to locate a legal guardian. However, unavailability of next of kin should not delay definitive intervention

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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

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

Correct Answer is A

Explanation

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Correct Answer is C

Explanation

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