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:

“I should take this medication with food to prevent stomach upset.” Rationale: This statement is not accurate for fluconazole. While some medications should be taken with food to reduce stomach upset, fluconazole is typically taken on an empty stomach. Taking it with food may reduce its absorption.

Choice B rationale:

“I should avoid drinking alcohol while taking this medication.” Rationale: This is the correct response. Fluconazole can interact with alcohol and may lead to increased side effects or reduced effectiveness of the medication. Therefore, it is essential to avoid alcohol while taking fluconazole.

Choice C rationale:

“I should use a barrier method of contraception while taking this medication.” Rationale: While it is generally a good practice to use barrier contraception during treatment for a fungal infection to prevent potential spread to a partner, this statement does not specifically address fluconazole's requirements or interactions.

Choice D rationale:

“I should stop taking this medication if I develop a rash.” Rationale: This statement is not entirely accurate. While it is important to monitor for skin rashes as they can be a sign of an allergic reaction, the decision to stop taking fluconazole should be made in consultation with a healthcare provider. It is not an automatic response to developing a rash.

The correct answer is choice c. Ensure that the call bell is easily accessible to the client.

Choice A rationale:

Reassuring the client that someone will check on him hourly is supportive but does not directly address the immediate need for the client to call for assistance if he needs to use the bathroom during the night.

Choice B rationale:

Placing fresh water and a glass within reach is helpful for hydration but may increase the need to urinate, which could exacerbate the issue of urinary frequency at night.

Choice C rationale:

Ensuring that the call bell is easily accessible allows the client to quickly and safely request assistance if he needs to use the bathroom, reducing the risk of falls and ensuring timely help.

Choice D rationale:

Offering an evening snack before providing oral care is a good practice for comfort and nutrition but does not directly address the issue of urinary frequency or the need for nighttime assistance.