A nurse is assessing a client who has septic shock. The nurse notes that the client has a blood pressure of 80/50 mmHg, a heart rate of 120 beats per minute, a respiratory rate of 28 breaths per minute, and a temperature of 39°C.

The nurse calculates that the client has a Sequential Organ Failure Assessment (SOFA) score of what value?

Provide supplemental oxygen as needed

Answer and Explanation

The Correct Answer is A

The SOFA score is a tool that assesses the degree of organ dysfunction or failure in septic shock. It is based on six parameters: blood pressure, Glasgow coma scale, PaO2/FiO2 ratio, platelet count, bilirubin level, and creatinine level. Each parameter is assigned a score from 0 to 4 based on the severity of the abnormality. The total SOFA score ranges from 0 to 24, with higher scores indicating worse organ dysfunction or failure.

The client's blood pressure of 80/50 mmHg corresponds to a SOFA score of 1, as it indicates hypotension.

The client's Glasgow coma scale is not given, so it is assumed to be normal (15), which corresponds to a SOFA score of 0.

The client's PaO2/FiO2 ratio is not given, so it is assumed to be normal (>400), which corresponds to a SOFA score of 0.

The client's platelet count is not given, so it is assumed to be normal (>150 x 10^9/L), which corresponds to a SOFA score of 0.

The client's bilirubin level is not given, so it is assumed to be normal (<20 micromol/L), which corresponds to a SOFA score of 0.

The client's creatinine level is not given, so it is assumed to be normal (<110 micromol/L), which corresponds to a SOFA score of 0.

The total SOFA score is the sum of the scores for each parameter: 1 + 0 + 0 + 0 + 0 + 0 = 1. Therefore, the client has a SOFA score of 1.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason:

Restricting fluid intake is not an action that the nurse should take for a client who has hypernatremia. Fluid restriction can worsen hypernatremia by increasing the concentration of sodium in the blood. Fluid intake should be increased or replaced with isotonic or hypotonic fluids to dilute sodium and correct hypernatremia.

Choice B reason:

Monitoring neurological status is an action that the nurse should take for a client who has hypernatremia. Hypernatremia can cause neurological symptoms such as confusion, agitation, seizures, coma, and death due to cellular dehydration and brain shrinkage. The nurse should assess the client's level of consciousness, orientation, memory, behavior, and reflexes regularly and report any changes or deterioration.

Choice C reason:

Administering hypotonic IV fluids is an action that the nurse should take for a client who has hypernatremia. Hypotonic fluids have a lower concentration of solutes than normal body fluids and can help lower serum sodium levels by moving water into the cells from the blood vessels. The nurse should administer hypotonic fluids slowly and carefully to avoid fluid overload or cerebral edema.

Choice D reason:

Encouraging foods high in sodium is not an action that the nurse should take for a client who has hypernat

A. Hydrocolloid dressing B. Transparent film dressing C. Calcium alginate dressing D. Hydrogel dressing

Correct Answer is A

Explanation

Choice B reason:

Transparent film dressing is a type of dressing that consists of a thin sheet of polyurethane with an adhesive coating. It allows oxygen and moisture vapor to pass through but prevents bacteria and water from entering the wound. It is suitable for wounds with minimal drainage, such as superficial abrasions or donor sites.

Choice C reason:

Calcium alginate dressing is a type of dressing that consists of fibers derived from seaweed that form a gel-like substance when they come in contact with wound exudate. It absorbs large amounts of drainage and supports autolytic debridement of necrotic tissue. It is suitable for wounds with heavy drainage, such as pressure ulcers or venous ulcers.

Choice D reason:

Hydrogel dressing is a type of dressing that consists of water or glycerin-based gel that provides moisture to dry wounds and supports autolytic debridement of necrotic tissue. It is suitable for wounds with minimal to moderate drainage, such as partial-thickness burns or radiation injuries.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is A

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