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 A

Explanation

A. A right foot that is pale with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, and requires immediate intervention to prevent tissue damage.
B. Circumferential edema of the right foot may be expected after a fracture and casting but does not indicate an immediate complication requiring intervention.
C. Reports of throbbing right leg pain are common after a fracture and casting and may be managed with appropriate pain medication but do not necessarily indicate an immediate complication.
D. An increased temperature to the lower extremity may be indicative of inflammation but does not necessarily require immediate intervention unless accompanied by other signs of infection or complications.

A. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. B. An 18-year-old client with antisocial behavior who is being yelled at by other clients. C. A 16-year-old client diagnosed with major depression who refuses to participate in group. D. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby

Correct Answer is D

Explanation

A. While concerning, a single refusal to eat is not immediately life-threatening.

B. While being yelled at could escalate, the situation is not as urgent as others.

C. While refusing to participate in group is concerning, it is not immediately life- threatening.
D. Pacing in a client with bipolar disorder may indicate agitation or the onset of a manic episode, which could lead to dangerous behavior and requires immediate attention.

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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?

Nursing Test Bank

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Correct Answer is D

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