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?
Maintain strict intake and output.
Keep head of bed raised 45 degrees.
Assess warmth of extremities.
Monitor blood glucose level.
The Correct Answer is A
A. Maintaining strict intake and output is crucial in managing septic shock, as it helps assess kidney function and fluid balance, which are vital in this critical condition.
B. Keeping the head of bed raised can help with respiratory function, but it is not the primary focus in septic shock management.
C. Assessing warmth of extremities is important but does not provide immediate information about the client’s hemodynamic status.
D. Monitoring blood glucose levels is important for overall care, especially if the patient is receiving insulin or has diabetes, but it is not the most critical intervention in the context of septic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["41.7"]
Explanation
To determine the amount of amoxicillin suspension the nurse should administer every 8 hours, follow these steps:
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Convert grams to milligrams: 5 grams = 5000 milligrams (since 1 gram = 1000 milligrams).
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Calculate the dose per 8 hours: 5000 milligrams / 3 doses per day = 1666.7 milligrams per dose.
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Convert milligrams to milliliters: Amoxicillin suspension is 200 mg/5 mL. (1666.7 milligrams) / (200 mg/5 mL) = 41.7 milliliters per dose.
So, the nurse should administer 41.7 mL of amoxicillin suspension every 8 hours.
Correct Answer is B
Explanation
A. While the nursing staff should be aware of the DNR status, the immediate concern is the client's expressed wishes regarding treatment.
B. Notifying the healthcare provider is essential so that the medical team can respect the client’s wishes, especially in an acute situation where life-saving measures are being discussed.
C. Placing a certified copy of the living will in the record is important, but it should be done after informing the healthcare provider.
D. Facilitating a family meeting may be helpful, but the priority is to communicate the client's wishes to the medical team immediately.
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