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","C","G","H"]

Explanation

A. While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B. Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C. The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D. This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E. The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F. This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G. The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume.

Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.

A. Low-fat dairy products. B. Fresh fruits and vegetables. C. Iron-rich meals. D. Water and herbal teas.

Correct Answer is A

Explanation

A: Dairy products such as milk, yogurt, and cheese are rich sources of calcium, which is essential for bone health and can help prevent osteoporosis, especially in older adults.
B: While fruits and vegetables are important for overall health, they do not provide significant amounts of calcium, which is the primary nutrient needed for preventing osteoporosis.
C: Iron-rich meals are important for preventing anemia but do not directly contribute to bone health and prevention of osteoporosis.
D: While hydration is important for overall health, water and herbal teas do not provide significant amounts of calcium needed for bone health.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","G","H"]

Explanation

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Correct Answer is A

Explanation

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