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 D

Explanation

Rationale

A. This response acknowledges the client's need for reassurance and informs them of the nurse's plan. However, it may not address the immediate need for comfort and connection expressed by the client.

B. This response may come across as dismissive or insensitive to the client's emotional and psychological needs. It could potentially increase anxiety or distress in an already vulnerable client.

C. Sitting beside the client demonstrates empathy and provides physical presence, which can be reassuring and comforting. However, it is not practical as the nurse has other duties to attend to.

D. It addresses the patient's immediate emotional needs without compromising the nurse's ability to perform their duties.

A. Neurology unit supervisor. B. Nurse case manager. C. Adult nurse practitioner. D. Risk management nurse.

Correct Answer is B

Explanation

Rationale

A. This role oversees the neurology unit but may not be directly involved in ICU care coordination, which requires a focus on acute management and transition to rehabilitation.

B. Nurse case managers are skilled in coordinating care for patients with complex conditions, ensuring continuity of care, and facilitating communication among healthcare providers and the client's family.

C. While an NP may be involved in direct patient care, their role is more focused on clinical management rather than comprehensive care coordination across different disciplines.

D. This role deals with patient safety and risk reduction but is not primarily responsible for coordinating care for a specific patient's acute medical needs and rehabilitation planning.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

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