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?

Keep head of bed raised 45 degrees.

Maintain strict intake and output.

Monitor blood glucose level.

Assess warmth of extremities.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Keeping the head of the bed raised 45 degrees is a crucial intervention in septic shock. This position helps improve oxygenation and reduces the risk of aspiration. It promotes better lung function and can help maintain a higher mean arterial pressure, which is important in the management of sepsis.

Choice B rationale:

Maintaining strict intake and output is important for assessing fluid balance, but it is not the most critical intervention when a client is in septic shock. Hemodynamic stability and oxygenation take precedence in this situation.

Choice C rationale:

Monitoring blood glucose levels is an essential aspect of care, especially in critically ill patients. However, it is not the most important intervention in the immediate management of septic shock.

Choice D rationale:

Assessing the warmth of extremities is important for circulatory assessment, but it is not the most crucial intervention in septic shock. Hemodynamic support and maintaining oxygenation are higher priorities.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale:
The client’s presentation of a noticeable facial droop and garbled speech are classic symptoms of a stroke. These symptoms indicate that the brain is not receiving enough oxygen, which can lead to permanent damage if not treated immediately. Therefore, this client requires immediate health interventions.
Choice B rationale:
This choice is identical to Choice A. The client’s noticeable facial droop and garbled speech are indicative of a stroke and require immediate attention.
Choice C rationale:
This choice is also identical to Choices A and B. The client’s symptoms are indicative of a stroke, which is a medical emergency that requires immediate intervention.
Choice D rationale:
While the change in the client’s speech after having a few drinks at a restaurant could be due to alcohol consumption, it could also be a symptom of a stroke, especially when combined with a facial droop. However, this choice does not directly indicate the need for immediate health interventions as it lacks the specificity of the symptoms compared to Choices A, B, and C.
Choice E rationale:
The time of arrival and mode of transportation do not directly indicate the need for immediate health interventions. However, the mention of facial drooping and garbled speech upon arrival at the emergency department reinforces the urgency of the situation, as these are classic symptoms of a stroke. In conclusion, Choices A, B, C, and E all highlight data that indicate the client is in need of immediate health interventions due to potential stroke symptoms. It’s important to note that strokes require immediate medical attention to minimize brain damage and potential complications. Normal ranges for lab parameters would not apply in this scenario as it’s based on clinical observations rather than laboratory findings.

A. Temperature of water B. The weight of the child C. Oxygen concentration of the ambient air D. Whether or not anyone witnessed the fall into the pool E. The amount of time the child was submerged

Correct Answer is ["A","E"]

Explanation

The level of hypoxemia that the child may have experienced during the submersion depends on several factors, but the most important ones are:

The **temperature of water**: Cold water can induce a diving reﬂex, which lowers the heart rate and oxygen consumption, and may protect the brain from hypoxic injury. Cold water can also cause laryngospasm, which prevents water aspiration but also impairs gas exchange.
The **amount of time the child was submerged**: The longer the submersion, the more severe the hypoxemia and the higher the risk of brain damage and death. The survival rate decreases significantly after 5 minutes of submersion.

The other factors are less relevant or not directly related to the level of hypoxemia:

The **weight of the child**: This may aﬀect the buoyancy and the ability to ﬂoat or swim, but not the oxygen consumption or gas exchange during submersion.
The **oxygen concentration of the ambient air**: This may aﬀect the pre-submersion oxygen saturation, but not the rate of oxygen depletion or gas exchange during submersion.
The **witnessing of the fall into the pool**: This may aﬀect the time to rescue and resuscitation, but not the level of hypoxemia during submersion.

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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

Correct Answer is ["A","B","C","E"]

Explanation

Correct Answer is ["A","E"]

Explanation

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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?