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 C

Explanation

The correct answer is choice C: Instruct the UAP to lower the bed for safety.

Choice C rationale: When bathing a bedfast client, the bed should be in a flat or low position to reduce the risk of the client sliding down, falling, or experiencing discomfort or injury. By instructing the UAP to lower the bed, the PN ensures client safety during the bathing process.

Choice A rationale: Assuming care of the client immediately might be unnecessary. The PN should first address the safety concern and then determine if additional intervention is needed.

Choice B rationale: While supervising the UAP may be appropriate in certain situations, the priority in this case is to address the immediate safety concern by instructing the UAP to lower the bed. The PN can then decide if supervision or assistance is required.

Choice D rationale: Determining if the UAP would like assistance is considerate, but it is not the priority in this situation. Ensuring client safety by lowering the bed should be addressed first. The PN can then assess whether the UAP needs any help or guidance.

A. CP is one of the most common permanent physical disabilities in children. B. Brain damage with CP is not progressive but does have a variable course. C. Severe motor dysfunction determines the extent of successful habilitation. D. Continued development of the brain lesion determines the child's outcome.

Correct Answer is B

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.

Choice D rationale:

Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro

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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

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in the high fowlers position. Which action should the PN take?

Correct Answer is C

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows.Which response provides the best explanation?

Correct Answer is B

Explanation

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?

The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:

A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery.Which action is most important for the nurse to implement?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room.Which action should the nurse take?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

A client has been diagnosed with depression and has a history of suicide attempts.What intervention is essential for the nurse to implement?

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?