The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

Evaluate pupil reactions every shift

Assess temperature every 4 hours

Monitor for cyanosis

Check reflexes

Answer and Explanation

The Correct Answer is C

Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.

Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.

Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.

Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.

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Correct Answer is D

Explanation

Choice A reason: Assessing for hematuria is important but not the priority action. Hematuria can be a symptom of various conditions and does not directly address the abnormal laboratory results.

Choice B reason: Monitoring temperature is a routine action in sepsis management but does not address the immediate concern of the abnormal laboratory results, specifically the elevated aPTT and low platelet count.

Choice C reason: Evaluating skin turgor is a method to assess dehydration, which is not the immediate concern indicated by the laboratory results.

Choice D reason: The elevated aPTT and low platelet count suggest a potential coagulopathy, which could be a sign of disseminated intravascular coagulation (DIC), a complication of sepsis. Administering heparin may be part of the treatment for DIC to prevent further clotting and is a priority action in this context.

A. Administer propylthiouracil (PTU). B. Provide an electric blanket. C. Restrict fluids. D. Monitor for hypotension.

Correct Answer is A

Explanation

Choice A reason: Propylthiouracil (PTU) is an antithyroid medication used to treat hyperthyroidism, which can present with symptoms such as weight loss and heat intolerance. The symptoms listed (periorbital edema, cold intolerance, and weight gain) suggest hypothyroidism, for which PTU is not indicated.

Choice B reason: Providing an electric blanket may offer comfort for cold intolerance but does not address the underlying thyroid disorder.

Choice C reason: Restricting fluids is not a standard intervention for thyroid disorders and could potentially lead to dehydration.

Choice D reason: Monitoring for hypotension is important in thyroid disorders, especially if the client is on antithyroid medications, which can affect blood pressure. However, the symptoms presented suggest hypothyroidism, where hypotension is less of a concern compared to hyperthyroidism.

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The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

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Correct Answer is D

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