The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Keep head of bed raised 45 degrees.

Monitor blood glucose level.

Maintain strict intake and output.

Assess warmth of extremities.

Answer and Explanation

The Correct Answer is B

A.   Elevating the head of the bed can help improve oxygenation but is not directly related to managing sepsis.
B.   Monitoring blood glucose levels is crucial in sepsis management as hyperglycemia can exacerbate the inflammatory response.
C.   While intake and output monitoring is important, it is not the priority in the early management of sepsis.
D.   Assessing warmth of extremities is important but not the most critical intervention in managing sepsis.

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Correct Answer is B

Explanation

A. While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The belief that their needs will be met through education fosters motivation.

C. Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.

A. Complete comprehensive assessments. B. Remove discontinued peripheral intravenous catheters. C. Evaluate and update plans of care for clients. D. Begin initial sterile wound care for surgical clients.

Correct Answer is B

Explanation

A. This task typically requires a more advanced level of clinical judgment and assessment skills, which are usually beyond the scope of practice for a PN and should be conducted by a Registered Nurse (RN).
B. Removing discontinued peripheral IV catheters is a task that falls within the scope of practice for a Practical Nurse (PN). It does not require the advanced assessment skills or judgment that some other tasks might require.
C. This involves critical thinking and clinical decision-making that are responsibilities typically reserved for an RN, as it requires integrating new information and adjusting care plans based on ongoing assessments.
D. While PNs can perform certain types of wound care, initiating sterile wound care for surgical clients often requires the advanced knowledge and assessment skills of an RN, particularly if the wound care involves evaluating surgical site integrity and potential complications.

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The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is B

Explanation

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