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?
Keep head of bed raised 45 degrees.
Monitor blood glucose level.
Maintain strict intake and output.
Assess warmth of extremities.
The Correct Answer is B
A. Elevating the head of the bed can help improve oxygenation but is not directly related to managing sepsis.
B. Monitoring blood glucose levels is crucial in sepsis management as hyperglycemia can exacerbate the inflammatory response.
C. While intake and output monitoring is important, it is not the priority in the early management of sepsis.
D. Assessing warmth of extremities is important but not the most critical intervention in managing sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.4"]
Explanation
To calculate the dosage of lorazepam for the client, first determine the total micrograms required by multiplying the client's weight in kilograms by the prescribed amount per kilogram. For a client weighing 65 kg prescribed 44 mcg/kg, the total dosage would be 65 kg x 44 mcg/kg, which equals 2860 mcg. Since the medication is available in a concentration of 2 mg/ml, convert the total dosage from micrograms to milligrams by dividing by 1000 (because there are 1000 micrograms in a milligram). This results in 2.86 mg. Finally, to find out how many milliliters to administer, divide the total milligrams needed by the concentration of the vial, which is 2 mg/ml. Therefore, 2.86 mg / 2 mg/ml equals 1.43 ml. When rounding to the nearest tenth, the nurse should administer 1.4 ml of lorazepam.
Correct Answer is B
Explanation
A. Elevating the head of the bed can help improve oxygenation but is not directly related to managing sepsis.
B. Monitoring blood glucose levels is crucial in sepsis management as hyperglycemia can exacerbate the inflammatory response.
C. While intake and output monitoring is important, it is not the priority in the early management of sepsis.
D. Assessing warmth of extremities is important but not the most critical intervention in managing sepsis.
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