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?

Maintain strict intake and output.

Assess warmth of extremities.

Monitor blood glucose level.

Keep head of bed raised 45 degrees.

Answer and Explanation

The Correct Answer is A

A. Maintaining strict intake and output is crucial in managing septic shock as it helps to monitor fluid balance, which is essential for managing hypovolemia and ensuring adequate perfusion.

B. While assessing warmth of extremities is important, it is not as directly related to the immediate management of septic shock as monitoring intake and output.

C. Monitoring blood glucose levels is important, especially in septic patients, but it is not the primary focus in the initial management of septic shock.

D. Keeping the head of the bed raised 45 degrees can help with breathing but is not the most critical intervention in the immediate management of septic shock.

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Correct Answer is B

Explanation

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B. Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C. Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D. Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

A. Initiate bilateral intermittent sequential pneumatic compression devices. B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. C. Maintain elevated positioning of the dependent joints on affected side. D. Obtain a focused history to determine recent bleeding and use of anticoagulants.

Correct Answer is B

Explanation

A. Initiating sequential pneumatic compression devices is not immediately relevant to managing acute stroke symptoms.

B. Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment helps reduce intracranial pressure and facilitates venous drainage, which is crucial in managing potential stroke patients.

C. Elevating the dependent joints on the affected side is not immediately necessary and does not address the acute neurological symptoms.

D. While obtaining a focused history is important, it should follow after initial stabilization measures such as positioning and securing immediate diagnostic tests.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is B

Explanation

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