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?

Choice A rationale:

Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.

Choice B rationale:

Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.

Choice C rationale:

Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.

Choice D rationale:

Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.

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.