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:

Administering protamine sulfate slowly intravenously within 30 minutes of heparin administration is not the recommended route and timing for reversing heparin's effects. Protamine sulfate is typically given slowly intravenously within 60 minutes of heparin administration.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly within 60 minutes of heparin administration is not the recommended route for this medication. Protamine sulfate should be given intravenously, not intramuscularly.

Choice C rationale:

Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration. This is the correct route and timing for reversing the anticoagulant effects of heparin.

Choice D rationale:

Administering protamine sulfate rapidly intramuscularly within 30 minutes of heparin administration is not the recommended route and timing for this medication. Intravenous administration is preferred for a more controlled and predictable reversal of heparin's effects.

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.