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?

The correct answer is choice c. Administer prescribed stool softener.

Choice A rationale:

Administering prescribed PRN sleep medications is not the highest priority. While rest is important, managing pain and preventing complications from the laceration take precedence.

Choice B rationale:

Encouraging the use of prescribed analgesic perineal sprays is beneficial for pain management, but it is not the highest priority intervention.

Choice C rationale:

Administering a prescribed stool softener is crucial because it helps prevent constipation, which can cause significant pain and strain on the perineal area, potentially worsening the laceration.

Choice D rationale:

Encouraging breastfeeding to promote uterine involution is important for postpartum recovery, but it does not directly address the immediate needs related to the fourth-degree laceration.

Choice A rationale:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.