The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Fluid volume deficit.

Caregiver role strain.

Bowel incontinence.

Impaired bed mobility.

Answer and Explanation

The Correct Answer is A

A.   Diarrhea can lead to significant fluid and electrolyte imbalances, especially in older adults. Prioritizing hydration and electrolyte management is essential to prevent severe complications like renal failure or shock.
B.   While caregiver stress is significant and must be addressed, it is not as immediately life-threatening as a fluid volume deficit.
C.   This is an ongoing management issue but does not pose an immediate threat to the client's life compared to fluid and electrolyte imbalances.
D.   Although important for overall care and prevention of complications such as pressure ulcers, it is not as critical as managing fluid volume deficit in this scenario.

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Correct Answer is ["B","H"]

Explanation

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

A. Keep head of bed raised 45 degrees. B. Monitor blood glucose level. C. Maintain strict intake and output. D. Assess warmth of extremities.

Correct Answer is C

Explanation

A. Raising the head of the bed can help improve lung expansion and reduce aspiration risk, which is beneficial for a client with pneumonia. However, while this intervention supports respiratory function, it does not directly address the systemic perfusion and organ failure risks associated with septic shock. Therefore, it is not the highest priority intervention in a sepsis protocol.
B. Blood glucose monitoring is important in sepsis because stress-induced hyperglycemia is common and uncontrolled glucose can worsen outcomes. However, this intervention is supportive rather than critical in the early management of septic shock and does not take priority over interventions that directly evaluate perfusion and organ function.
C. Strict intake and output monitoring is essential in septic shock because it provides immediate information about renal perfusion and fluid balance. Septic shock causes widespread vasodilation and capillary leak, leading to decreased organ perfusion and acute kidney injury. Urine output is a key indicator of organ function and response to fluid resuscitation, making this intervention a core component of sepsis management.
D. Assessing extremity warmth helps evaluate peripheral perfusion and can indicate early versus late septic shock. While this is a useful assessment, it is less critical than objective measures such as urine output that directly reflect organ perfusion and guide treatment decisions.

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The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","H"]

Explanation

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is C

Explanation

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