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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Ensuring that someone stays with the client for 24 hours is important for immediate postoperative care but does not directly ensure compliance with self-care instructions.
B. The teach-back method involves asking the client to repeat in their own words the instructions you just provided. This confirms that they understand the information correctly and are able to follow it at home. For a client with hearing difficulties, this ensures that any miscommunication is identified and corrected before discharge, improving compliance and safety.
C. Speaking clearly and facing the client for lip reading is helpful for communication but does not ensure that the client fully understands and can follow the instructions.
D. Providingwritten instructions for eye drop administrationis useful as a supplement, but written instructions may not guarantee understanding, especially if the client has visual limitations or confusion.

A. Hard, painless nodule over metatarsophalangeal joint of first toe. B. Erythema and edema at the base of the left great toe. C. Decreased response to pain discrimination on dorsal surface of foot. D. Painful corns and calluses over hammer toes on both feet.

Correct Answer is B

Explanation

A. A hard, painless nodule may indicate a deformity but is not an emergency.

B. Erythema and edema at the base of the left great toe could indicate an infection, such as cellulitis, which requires immediate intervention to prevent complications.
C. Decreased response to pain discrimination suggests neuropathy, which is concerning but not immediately life-threatening.
D. Painful corns and calluses are chronic issues that need management but are not urgent.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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