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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The statement, "This medication will help regulate my mood and anxiety," is an accurate description of how antidepressants work. Antidepressants can help improve mood and reduce anxiety symptoms over time.
Choice B rationale:
This is the correct answer. Expecting immediate results from antidepressant medication is a misunderstanding. Antidepressants typically take several weeks to show their full therapeutic effects. Clients need to be informed about the delayed onset of action.
Choice C rationale:
The statement, "I may experience side effects such as nausea and drowsiness," is accurate. Antidepressants can indeed cause side effects, including gastrointestinal symptoms like nausea and drowsiness. This information is essential for the client to be aware of.
Choice D rationale:
This statement is correct. It is crucial to take antidepressant medication consistently as prescribed for the best therapeutic outcomes. Stopping or missing doses without consulting a healthcare provider can lead to treatment ineffectiveness.
Correct Answer is A
Explanation
a) Suggest an increase in fruits and vegetables is more beneficial.
In this scenario, the dentist is increasing the amount of dairy products in her diet with the aim of reducing the risk of gingivitis due to her family history of cancer. However, the practical nurse (PN) should respond by suggesting that an increase in fruits and vegetables would be more beneficial.
Fruits and vegetables are rich in essential vitamins, minerals, and antioxidants, which can help support overall oral health and reduce the risk of gingivitis. They provide a wide range of nutrients that are important for maintaining healthy gums and teeth.
While dairy products can contribute to overall dental health due to their calcium content, they should not be solely relied upon as the primary means of preventing gingivitis or reducing the risk of cancer. A well- rounded and balanced diet, including plenty of fruits and vegetables, is essential for optimal oral health.
Options b, c, and d are not directly related to the dentist's concern about gingivitis and the increased consumption of dairy products. Encouraging exercise (option b) is generally beneficial for overall health, but it does not specifically address gingivitis. Reminding the client to ensure dairy products are fortified with vitamin D (option c) is not necessary in this context, as the focus is on preventing gingivitis rather than addressing vitamin D deficiency. Providing writen information about the warning signs of cancer (option d) is not directly relevant to the dentist's current situation and concern about gingivitis.
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