What is the nurse's priority when caring for a patient in septic shock?
Maintaining strict bed rest
Administering pain medication
Monitoring vital signs frequently
Assisting with daily hygiene
The Correct Answer is C
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Serum sodium levels are important to monitor over time with diuretic therapy but do not provide immediate feedback on the effect of a bolus dose of furosemide.
B. Daily weight helps assess long-term fluid status but is not helpful for evaluating an acute response.
C. Hourly urine output is the most appropriate and immediate measure to assess the effectiveness of a bolus dose of IV furosemide, especially in a critically ill client with acute pulmonary edema.
D. 24-hour intake and output provides a broader picture but does not offer real-time assessment like hourly output does.
Correct Answer is D
Explanation
A. Hemoglobin is important for evaluating oxygen-carrying capacity but is not directly related to digoxin safety.
B. Blood urea nitrogen (BUN) is useful in assessing renal function but is not the priority for digoxin administration.
C. Creatinine is also important for renal function assessment, especially since digoxin is renally excreted, but it is still secondary to potassium.
D. Potassium is the priority lab value to review before giving digoxin, because hypokalemia increases the risk of digoxin toxicity, which can lead to serious arrhythmias. Monitoring and correcting potassium levels is essential for client safety.
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