A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Monitor blood glucose level.

Maintain strict intake and output.

Keep head of bed raised 45 degrees.

Assess warmth of extremities.

Answer and Explanation

The Correct Answer is B

Rationale for A: Monitoring blood glucose levels is important in septic patients as hyperglycemia can occur due to stress response, and insulin resistance may develop. However, it is not the most critical intervention for immediate stabilization.
Rationale for B: Maintaining strict intake and output is crucial for a patient in septic shock because fluid balance is a key component in managing shock. Accurate measurement of intake and output ensures appropriate fluid resuscitation, which is vital for maintaining blood pressure and organ perfusion.
Rationale for C: Keeping the head of the bed raised 45 degrees can help prevent aspiration, which is particularly important in patients who are at risk of gastrointestinal bleeding or those who are sedated. However, this is not the primary intervention for septic shock management.
Rationale for D: Assessing the warmth of extremities can provide information about peripheral circulation and may indicate the effectiveness of cardiac output. Nevertheless, it is not the most immediate concern in the management of septic shock.

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Correct Answer is D

Explanation

A. Verify the prothrombin time (PT).
While it is important to verify coagulation status in patients with atrial fibrillation to ensure they are not at high risk for bleeding, this is not the most critical step immediately prior to
cardioversion. The PT is more relevant if anticoagulation therapy is being managed.

B. Administer prescribed sedative.
Administering a sedative is important for patient comfort during the procedure, but it is not the most critical step that directly affects the success and safety of the cardioversion itself.

C. Select a monitor lead with a tall R wave.
Selecting a monitor lead with a tall R wave helps in accurately synchronizing the cardioversion shock with the R wave, but this is secondary to activating the synchronization mode which is critical to avoid delivering a shock during the vulnerable period of the cardiac cycle.

D. Activate the synchronization mode.
This is the correct answer. The most important action before deploying the current for cardioversion is to ensure the defibrillator is in synchronization mode. Synchronization ensures that the electrical shock is delivered at the correct time during the cardiac cycle, specifically on the R wave of the QRS complex, to avoid inducing ventricular fibrillation. This is crucial for
patient safety.

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. B. The choice of treatment is best determined by the sensitivity of these genetic markers. C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. D. The prognosis of breast cancer is most successful when these markers are inherited mutations.

Correct Answer is C

Explanation

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. This is not accurate; BRCA1 and BRCA2 genes are involved in DNA repair, and mutations in these genes increase cancer risk.
B. The choice of treatment is best determined by the sensitivity of these genetic markers. While genetic markers can influence treatment decisions, this option does not directly address the role of BRCA1 and BRCA2 mutations in cancer risk.
C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. This is correct. Mutations in these genes significantly increase the risk of developing breast and ovarian cancer.
D. The prognosis of breast cancer is most successful when these markers are inherited mutations.
This statement is incorrect. The presence of BRCA1 or BRCA2 mutations influences risk, not necessarily prognosis or treatment success.

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A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. 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

Correct Answer is D

Explanation

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

Correct Answer is C

Explanation

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