The nurse is caring for an 85-year-old patient with septic shock.
What should the nurse consider when repositioning this patient?
Place the patient in the Trendelenburg position.
Change the patient’s position slowly.
Reduce the oxygen flow.
Increase the IV fluid flow.
The Correct Answer is B
Choice A rationale
The Trendelenburg position, which involves laying the patient flat on their back with their legs elevated higher than their head, is not recommended for patients with septic shock. This position can increase intracranial pressure and does not improve circulation or oxygenation.
Choice B rationale
Changing the patient’s position slowly is important in managing an elderly patient with septic shock. Rapid changes in position can cause a drop in blood pressure (orthostatic hypotension), which can lead to falls or decreased perfusion to vital organs.
Choice C rationale
Reducing the oxygen flow is not recommended for patients with septic shock. These patients often have difficulty with oxygenation and may require supplemental oxygen to maintain adequate oxygen levels.
Choice D rationale
Increasing the IV fluid flow is part of the initial management of septic shock to restore perfusion, but it should be done based on careful assessment and monitoring of the patient’s response to fluids. Overzealous fluid resuscitation can lead to fluid overload and complications such as pulmonary edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
Choice B rationale
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
Choice C rationale
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
Choice D rationale
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.
Correct Answer is D
Explanation
Choice A rationale
While pain management is important in burn care, the first action should be to stop the burning process. Administering IV morphine does not achieve this.
Choice B rationale
Applying ice to a burn can cause vasoconstriction and may increase tissue damage. It is not the first action to stop the burning process.
Choice C rationale
Applying a neutralizing agent is not the first action in chemical burn management. The priority is to remove the chemical from contact with the skin.
Choice D rationale
Removing the patient’s clothing is the first action in burn management. This prevents further contact of the chemical with the skin and stops the burning process.
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