A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.
The healthcare provider has prescribed a sepsis protocol to be initiated.
Which intervention should the nurse prioritize in the plan of care?

Keep the head of the bed raised 45 degrees.

Assess the warmth of the extremities.

Maintain strict intake and output records.

Monitor the patient’s blood glucose level.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Keeping the head of the bed raised 45 degrees is a common practice in intensive care units to prevent aspiration pneumonia. However, in the context of septic shock, this intervention is not the highest priority.

Choice B rationale

Assessing the warmth of the extremities can provide information about peripheral perfusion. Cold extremities may indicate poor perfusion, a common symptom in septic shock. However, this is not the most critical intervention in the management of septic shock.

Choice C rationale

Maintaining strict intake and output records is crucial in the management of septic shock. Fluid balance is a key component of sepsis management. Monitoring fluid balance helps ensure that the patient is adequately hydrated, which is essential for maintaining blood pressure and organ perfusion.

Choice D rationale

Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or has a history of diabetes. However, in the context of septic shock, this is not the highest priority.

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Correct Answer is {"dropdown-group-1":"C"}

Explanation

Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developingC. Postpartum hemorrhage.

The client’s laboratory results show a decrease in red blood cells (RBC), hematocrit, and hemoglobin levels, which are all signs of blood loss. Additionally, the nurse’s notes mention moderate lochia rubra with small clots, which could be a sign of postpartum hemorrhage. The firm fundus at the umbilicus is a good sign, but the blood loss output and decreased blood values indicate that the client is at risk for postpartum hemorrhage.

A. Provide counseling that most contraceptives protect against infection. B. Clarify that all STIs are transmitted through sexual intercourse. C. Emphasize that using safe sex practices removes the risk of STIs. D. Explain that reinfections occur from sex with untreated partners.

Correct Answer is D

Explanation

Choice A rationale

While it’s true that many contraceptives can help prevent certain sexually transmitted infections (STIs), they are not 100% effective. Condoms, for instance, can reduce the risk of STIs that are spread through bodily fluids, such as gonorrhea and chlamydia. However, they are less effective at protecting against STIs that are transmitted through skin-to-skin contact, such as herpes and human papillomavirus (HPV)1.

Choice B rationale

Not all STIs are transmitted through sexual intercourse. Some STIs, such as herpes and HPV, can be spread through skin-to-skin contact. Others, like HIV and hepatitis B and C, can also be spread through sharing needles or from mother to child during childbirth.

Choice C rationale

Safe sex practices can significantly reduce, but not completely remove, the risk of STIs. These practices include using condoms correctly every time you have sex, getting tested regularly for STIs, and limiting the number of sexual partners.

Choice D rationale

Reinfections can indeed occur from having sex with untreated partners. This is particularly true for bacterial STIs like syphilis. If a person’s partner is not treated, the bacteria can remain in their body and they can pass the infection back to the person after they’ve been treated.

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A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.The healthcare provider has prescribed a sepsis protocol to be initiated.Which intervention should the nurse prioritize in the plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"C"}

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis.The client reports having unprotected sex.Which response should the nurse provide?

Correct Answer is D

Explanation

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A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.
The healthcare provider has prescribed a sepsis protocol to be initiated.
Which intervention should the nurse prioritize in the plan of care?