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 ["D","E"]

Explanation

A. Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.

B. Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C. Locking the knees can lead to loss of balance and is not a recommended posture.

D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.

A. Ensure that the restraints are snug against the client's wrists. B. Ensure that the knot can be quickly released. C. Tie the knot with a double turn or square knot. D. Move the ties so the restraints are secured to the side rails.

Correct Answer is B

Explanation

A. Restraints should be secure but not too tight to prevent injury or impaired circulation.
B. Ensuring the knot can be quickly released is critical for the client's safety in case of emergency.
C. A double turn or square knot would make the restraint difficult to remove quickly, posing a safety risk.
D. Restraints should never be tied to side rails as this can cause injury if the rails are moved.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Correct Answer is ["D","E"]

Explanation

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Correct Answer is B

Explanation

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