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 A
Explanation
A. High-quality CPR with minimal interruptions is the cornerstone of asystole management. Asystole is a non-shockable rhythm, so maintaining perfusion through effective chest compressions and administering appropriate medications (like epinephrine) is essential.
B. Cessation of resuscitation efforts after only 2 minutes is inappropriate; the decision to stop should be based on the clinical scenario and response to interventions over time.
C. Narcan (naloxone) is used for opioid overdose, not for treating asystole unless there is a suspected opioid-related cause—and it does not directly restore electrical cardiac rhythm.
D. Defibrillation is not indicated in asystole, as it is a non-shockable rhythm. Continuous defibrillation is ineffective and inappropriate.
Correct Answer is C
Explanation
A. The T wave is in the inverted position – In a normal sinus rhythm, the T wave should be upright in most leads. An inverted T wave may indicate ischemia or other pathology.
B. The P-R interval measures 0.22 seconds – A normal P-R interval is between 0.12 and 0.20 seconds. A P-R interval of 0.22 seconds suggests a first-degree heart block.
C. The P wave falls before the QRS complex – In normal sinus rhythm, each P wave precedes a QRS complex, indicating that the electrical impulse originates from the sinoatrial (SA) node.
D. The QRS duration is 0.20 seconds – A normal QRS duration is 0.06 to 0.10 seconds. A QRS duration of 0.20 seconds is prolonged and suggests a conduction abnormality such as a bundle branch block.
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