A patient 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?
Keep the head of the bed raised 45 degrees.
Monitor the patient’s blood glucose level.
Assess the warmth of the patient’s extremities.
Maintain strict intake and output.
The Correct Answer is D
Choice A rationale
Keeping the head of the bed raised 45 degrees can help improve lung expansion and reduce the risk of aspiration, which is particularly important for patients who are intubated or receiving enteral nutrition. However, it is not the most important intervention for a patient with septic shock.
Choice B rationale
Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or parenteral nutrition, as these can increase blood glucose levels. However, it is not the most important intervention for a patient with septic shock.
Choice C rationale
Assessing the warmth of the patient’s extremities can provide information about peripheral perfusion and may be useful in monitoring the patient’s response to treatment. However, it is not the most important intervention for a patient with septic shock.
Choice D rationale
This is the correct answer. Maintaining strict intake and output is crucial in managing a patient with septic shock. Fluid balance is a key component of managing septic shock, and accurate intake and output measurements are essential for guiding fluid resuscitation and assessing the patient’s response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F"]
Explanation
Choice D rationale
Involving the mother in the decision-making process can help alleviate some of the stress associated with caregiving. It allows the mother to maintain some control over her care and ensures that her needs and preferences are being met.
Choice E rationale
It is normal to have mixed feelings when caring for a loved one. Acknowledging these feelings can be an important part of managing caregiver stress.
Choice F rationale
Taking time for oneself and maintaining other relationships is crucial for caregiver well-being. It can help prevent burnout and improve the quality of care provided to the mother.
Correct Answer is D
Explanation
Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the best method for administering the medication. This would dilute the dextrose, potentially reducing its effectiveness.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the best method for administering the medication. This would significantly dilute the dextrose, potentially reducing its effectiveness.
Choice C rationale
Asking the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the best method for administering the medication. This would not provide the immediate glucose boost needed to counteract insulin shock.
Choice D rationale
Pushing the undiluted dextrose slowly through the currently infusing IV is the best method for administering the medication. This allows for rapid administration of a concentrated glucose solution, which is necessary to quickly raise blood glucose levels in a patient experiencing insulin shock.
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