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 B

Explanation

Rationale

A. Starting IV infusion for antiviral drugs is premature without confirmation of COVID-19 diagnosis. Antiviral treatment for COVID-19 is typically initiated based on positive test results and clinical assessment by the healthcare provider. It is important to wait for test results before starting specific treatment protocols.

B. Given the client's symptoms and exposure history to someone with COVID-19, it is crucial to implement droplet precautions. This includes placing the client in a private room with the door closed to minimize the risk of airborne transmission. Healthcare providers should wear appropriate personal protective equipment (PPE), including masks (N95 respirator or surgical mask), gown, gloves, and eye protection, when entering the room.

C. This action is appropriate to inform family members about potential exposure to COVID-19. Symptoms can develop up to 14 days after exposure, so monitoring for symptoms is essential. However, immediate isolation and precautions for the client are more critical at this stage.

D. While it is important for the client to inform others about potential exposure, the immediate concern is implementing isolation precautions for the client and preventing further transmission within the healthcare setting.

A. Notify the healthcare provider if the client reports any allergies to iodine or shellfish. B. Insert an indwelling urinary catheter prior to going to the x-ray department. C. Encourage the client to drink at least 3 to 4 liters of water prior to the procedure. D. Instruct the client that it will be necessary to keep the legs straight for 6 to 8 hours after the procedure.

Correct Answer is A

Explanation

Rationale

A. Iodinated contrast dye is commonly used in IVP procedures. Clients with a known allergy to iodine or shellfish may be at increased risk of an allergic reaction to the contrast dye. It is crucial to notify the healthcare provider so that appropriate pre-medication or alternative imaging options can be considered to minimize the risk of an allergic reaction.

B. While some procedures may require a urinary catheter, it is not routinely necessary for an IVP. Urinary catheters are generally used when precise urinary output measurement is required or when there are concerns about bladder function during and after the procedure. There is no specific indication for routine urinary catheterization before an IVP.

C. Drinking plenty of fluids before an IVP helps to ensure adequate hydration and can help flush the contrast dye from the body more quickly after the procedure. This can help reduce the risk of contrast dye-related complications such as nephrotoxicity and contrast-induced nephropathy.

D. After an IVP, there is no requirement for the client to keep their legs straight for an extended period. Typically, clients are observed for a brief period after the procedure to monitor for any immediate adverse reactions, but they are not required to keep their legs straight or remain immobile for an extended duration.

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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

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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