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?

Keep head of bed raised 45 degrees.

Maintain strict intake and output.

Monitor blood glucose level.

Assess warmth of extremities.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Keeping the head of the bed raised 45 degrees is a crucial intervention in septic shock. This position helps improve oxygenation and reduces the risk of aspiration. It promotes better lung function and can help maintain a higher mean arterial pressure, which is important in the management of sepsis.

Choice B rationale:

Maintaining strict intake and output is important for assessing fluid balance, but it is not the most critical intervention when a client is in septic shock. Hemodynamic stability and oxygenation take precedence in this situation.

Choice C rationale:

Monitoring blood glucose levels is an essential aspect of care, especially in critically ill patients. However, it is not the most important intervention in the immediate management of septic shock.

Choice D rationale:

Assessing the warmth of extremities is important for circulatory assessment, but it is not the most crucial intervention in septic shock. Hemodynamic support and maintaining oxygenation are higher priorities.

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Correct Answer is C

Explanation

Choice A rationale:

The neurology unit supervisor is not the most appropriate nurse to coordinate the progression of care for a client with a spinal cord injury (SCI). While they may have expertise in neurology, the nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including SCI. They can facilitate communication between various healthcare providers and ensure that the client receives comprehensive care throughout their stay.

Choice B rationale:

An adult nurse practitioner may have specialized knowledge in the care of adults, but they may not have the specific skills and training required to coordinate the care of a client with a spinal cord injury in the ICU. Nurse case managers are better equipped to manage complex cases and ensure the continuity of care for the client.

Choice D rationale:

A risk management nurse focuses on minimizing healthcare-related risks and ensuring the safety of patients and staff. While their role is essential, it is not the primary responsibility to coordinate the progression of care for a client with a spinal cord injury. The nurse case manager is better suited for this role as they specialize in care coordination.

A. Gather the procedure tray and equipment. B. Cleanse the site and cover with a sterile towel. C. Keep the patient NPO (nothing by mouth) and encourage them to void. D. Place the patient in an orthopneic position.

Correct Answer is A

Explanation

The correct answer is choice A. Gather the procedure tray and equipment.

Choice A rationale:

The practical nurse should gather the necessary procedure tray and equipment to ensure everything is ready for the healthcare provider to perform the thoracentesis efficiently and safely.

Choice B rationale:

Cleansing the site and covering it with a sterile towel is part of the procedure itself and should be done by the healthcare provider performing the thoracentesis.

Choice C rationale:

Keeping the patient NPO (nothing by mouth) and encouraging them to void is not necessary for a thoracentesis. This procedure typically does not require the patient to be NPO.

Choice D rationale:

Placing the patient in an orthopneic position (sitting up and leaning forward) is important for the procedure, but it should be done closer to the time of the procedure, not necessarily as a preparatory step.

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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?

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Naxlex Comprehensive Predictor Exams

A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision.Which nurse should be contacted to coordinate the progression of the client's care?

Correct Answer is C

Explanation

A client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure?

Correct Answer is A

Explanation

The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:

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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?