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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.8"]
Explanation
Steps to solve:
- Convert the client's weight from pounds to kilograms:
- Weight (kg) = Weight (pounds) / 2.20462
- Weight (kg) = 132 pounds / 2.20462 ≈ 59.87 kg (round to nearest tenth for medication calculation)
- Calculate the total dantrolene dosage based on the prescribed dosage per kilogram:
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- Dosage (mg) = Weight (kg) x Dosage per kg
-
- Dosage (mg) = 59.87 kg x 1.5 mg/kg
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- Dosage (mg) ≈ 89.8 (round to nearest tenth)
- Determine the concentration of dantrolene after reconstitution:
- Concentration = 50 mg/mL (given on the vial label)
- Calculate the volume of the solution to administer:
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- Volume (mL) = Dosage (mg) / Concentration (mg/mL)
-
- Volume (mL) = 89.8 mg / 50 mg/mL
-
- Volume (mL) ≈ 1.79 mL (round to one decimal place)= 1.8mL
Correct Answer is ["100"]
Explanation
- Total volume of the infusion: 50 mL (saline bag)
- Infusion time: 30 minutes = 0.5 hours (convert minutes to hours)
- We don't need the concentration of gentamicin for this calculation because we're only interested in the total volume delivered per hour.
- Flow rate: Since all the medication is delivered within the infusion time, the flow rate is equal to the total volume divided by the infusion time.
Flow rate (mL/hour) = Total volume (mL) / Infusion time (hours)
Flow rate = 50 mL / 0.5 hours Flow rate = 100.0 mL/hour
Therefore, the nurse should set the pump to deliver 100.0 mL/hour to infuse the 60 mg of gentamicin over 30 minutes.
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