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 C
Explanation
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.
Correct Answer is B
Explanation
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.
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