The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Monitor blood glucose level.

Maintain strict intake and output.

Assess warmth of extremities.

Keep head of bed raised 45 degrees.

Answer and Explanation

The Correct Answer is B

Rationale

A. Monitoring blood glucose levels is important, especially in critically ill patients, as hyperglycemia can worsen outcomes in septic shock. However, it is not the most critical intervention in the immediate management of septic shock.

B. Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

C. Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

D. Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

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Correct Answer is A

Explanation

Rationale

A. This action helps maintain adequate cerebral perfusion pressure and venous drainage, which is important in suspected stroke cases. It supports optimal cerebral blood flow and reduces the risk of increased intracranial pressure. However, it's not the immediate intervention required for this client. The primary focus initially is on diagnostic evaluation and stabilization.

B. Elevating the joints on the affected side can help reduce dependent edema and promote circulation. This intervention is part of ongoing nursing care to prevent complications like deep vein thrombosis (DVT) in stroke patients who may have reduced mobility. While important, it is not the immediate priority in the acute phase of management.

C. Gathering a focused history is crucial to understanding potential causes or exacerbating factors contributing to the client's symptoms While important, it is not the immediate priority in the acute phase of management.

D. Intermittent pneumatic compression devices (IPC) are used to prevent deep vein thrombosis (DVT) by enhancing venous return and preventing stasis in the lower extremities. While DVT prevention is important in stroke patients, it is not the immediate intervention required for the client's acute neurological symptoms.

A. Assess distal lower extremity capillary refill. B. Check femoral site for hematoma formation. C. Evaluate the integrity of the IV insertion site. D. D Stimulate the client to take deep breaths.

Correct Answer is B

Explanation

Rationale

A. This action involves assessing the capillary refill of the lower extremity distal to the femoral site. It helps in evaluating peripheral perfusion and circulation to ensure there is no compromise to blood flow. This is important because decreased capillary refill could indicate impaired circulation, possibly due to arterial occlusion or hematoma formation.

B. Checking the femoral insertion site for hematoma formation is crucial after a cardiac catheterization. Hematomas can develop due to bleeding from the femoral artery puncture site, especially if the client is receiving anticoagulant therapy like heparin. A hematoma can compress surrounding structures, potentially causing pain and compromising circulation.

C. While it's important to assess the integrity of IV insertion sites, in this scenario, the primary concern is the groin insertion site used for cardiac catheterization. The IV insertion sites should be assessed regularly for signs of infiltration, phlebitis, or infection, but this should not take precedence over assessing the femoral insertion site for complications related to the procedure.

D. Deep breathing exercises are important for preventing respiratory complications such as atelectasis and pneumonia, especially in clients who are sedated and immobilized. However, in the context of acute pain at the femoral insertion site post-cardiac catheterization, assessing and addressing potential complications related to the procedure take priority.

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The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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