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 B

Explanation

Choice A rationale:
Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.
Choice C rationale:
Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.
Choice D rationale:
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

A. Hypertension. B. Apical heart rate 72 beats/minute. C. Muscle weakness. D. Blood pressure 90/76 mm Hg.

Correct Answer is A

Explanation

Choice A rationale:

The contraindication for administering clonidine in this scenario is hypertension. Clonidine is an antihypertensive medication and can lower blood pressure. If the client has hypertension, giving clonidine could exacerbate the problem and cause further reduction in blood pressure, potentially leading to complications.

Choice B rationale:

An apical heart rate of 72 beats/minute is within the normal range for adults and is not a contraindication for administering clonidine. Clonidine primarily affects blood pressure and should be used cautiously in clients with hypertension, but it does not directly impact heart rate.

Choice C rationale:

Muscle weakness is not a contraindication for administering clonidine. Clonidine is not known to cause muscle weakness as a side effect. It primarily affects blood pressure regulation.

Choice D rationale:

A blood pressure of 90/76 mm Hg is lower than the normal range for blood pressure, but it is not a contraindication for administering clonidine. In fact, clonidine is often used to lower blood pressure in hypertensive individuals. However, in this scenario, the client's low blood pressure should be carefully monitored, and the nurse should consider adjusting the clonidine dose if necessary to avoid excessive hypotension.

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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

While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values.

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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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?