Share This Link

Applying antibiotic ointment to mucous membranes is not a standard or effective intervention for preventing systemic infection or septic shock. Prophylactic topical antibiotics do not reduce the risk of urosepsis and may contribute to antimicrobial resistance.

Passive range-of-motion exercises promote mobility and circulation but do not directly reduce the risk of infection progression or septic shock. They are supportive measures rather than infection-prevention strategies.

Initiating total parenteral nutrition may be necessary in some clients who cannot meet nutritional needs enterally, but it does not directly reduce the risk of septic shock. In fact, TPN itself can increase infection risk if central venous access is required.

Decreasing intracranial pressure is a critical concern in clients with suspected head injury, but it is not the immediate priority until the airway and breathing are secured. Without adequate oxygenation, efforts to manage intracranial pressure will be ineffective and neurological injury will worsen.

Stabilizing cardiac arrhythmias addresses circulation, which is important in trauma care, but it comes after airway and breathing have been ensured. Additionally, arrhythmias may be secondary to hypoxia, meaning airway management may correct the underlying cause.

Preventing musculoskeletal disability focuses on long-term functional outcomes. While important during recovery and rehabilitation, it is not a priority during the acute, life-threatening phase of trauma management.

A urinary tract infection is likely the source of infection, as indicated by the cloudy urine and Foley catheter; however, the presence of systemic signs such as fever, tachycardia, tachypnea, altered mental status, and flushed skin indicates that the infection has progressed beyond a localized UTI. Therefore, UTI alone does not fully explain the patient’s current condition.

Hypodynamic sepsis (late sepsis) typically presents with cool, pale, clammy skin, hypotension, decreased cardiac output, and signs of poor perfusion. These findings are not present in this patient, making this option incorrect.

Toxic shock syndrome presents with sudden high fever, hypotension, diffuse rash, and multisystem involvement, often associated with tampon use or surgical wounds. The clinical presentation and urinary source of infection do not support this diagnosis.

A blood pressure of 84/50 mm Hg indicates hypotension, which is characteristic of the progressive (decompensatory) stage of shock. In the compensatory stage, blood pressure is usually maintained within normal limits due to vasoconstriction and increased heart rate.

Anuria reflects severe and prolonged renal hypoperfusion and is associated with the progressive or irreversible stages of shock. In the compensatory stage, urine output may be decreased but is not completely absent.

Petechiae are small pinpoint hemorrhages often associated with clotting abnormalities such as disseminated intravascular coagulation (DIC), which can occur in severe sepsis or late stages of shock. They are not a typical finding of the compensatory stage.

Slowing the IV infusion rate would be inappropriate in this situation. The patient’s low CVP, hypotension, flat jugular veins, and clear lung sounds all indicate hypovolemia rather than fluid overload. Reducing fluids would worsen tissue perfusion and shock.

Administering dopamine, a vasopressor, is not the first-line intervention in this case. Vasopressors are typically considered after adequate fluid resuscitation has been attempted. Because this patient shows clear signs of volume depletion, correcting hypovolemia with fluids is the priority before initiating medications to support blood pressure.

No intervention is not appropriate. The patient is hypotensive (90/50 mmHg) with a low CVP (normal is approximately 2–6 mmHg), indicating inadequate circulating volume. Without intervention, the patient is at risk for worsening shock and organ hypoperfusion.

Palpating for abdominal tenderness may help assess abdominal pathology, but it does not directly evaluate the effectiveness of pantoprazole. Protonix is not prescribed to relieve abdominal tenderness in SIRS.

Auscultating bowel sounds assesses gastrointestinal motility, not gastric acid suppression or prevention of stress-related mucosal damage. Therefore, it does not measure the therapeutic effect of pantoprazole.

Asking the patient about nausea assesses gastrointestinal comfort but does not specifically reflect the effectiveness of pantoprazole in preventing stress ulcers or GI bleeding.

Age of the client is an important consideration in overall prognosis and healing potential, as older adults and very young clients have higher morbidity and mortality from burns. However, age does not take priority over factors that immediately affect airway, breathing, and functional outcomes when determining burn severity.

Associated medical history, such as diabetes or cardiovascular disease, can influence healing and risk for complications, but it is a secondary consideration compared with the immediate threat posed by burns in critical areas.

Cause of the burn (thermal, chemical, electrical, or radiation) influences treatment decisions and potential complications, but it is not the primary factor when initially determining severity compared with burn location.

Cyanotic or mottled skin occurs in the progressive or decompensated stage of shock when tissue perfusion is significantly impaired. In the compensatory stage, skin may appear cool and pale due to vasoconstriction, but frank cyanosis is not yet present.

Blood pressure in the compensatory stage is usually maintained within normal limits due to vasoconstriction and increased heart rate. A BP of 115/74 is normal and does not indicate compensatory shock on its own. Hypotension develops later in the progressive stage.

Hypoglycemia is not a characteristic finding of the compensatory stage of shock. Early shock may actually lead to hyperglycemia due to stress hormone release (catecholamines and cortisol), which increases gluconeogenesis and glycogenolysis.

Inserting an indwelling urinary catheter may be necessary for accurate monitoring of urine output in burn patients, but it is not the immediate priority in the emergency assessment. Urinary monitoring is important after airway and breathing have been assessed and stabilized.

Administering intravenous pain medication is important for comfort and to reduce stress response, but it does not take priority over assessing and securing the airway in a burn patient. Pain management should be initiated after life-threatening conditions are addressed.

Drawing blood for a CBC helps assess hemoglobin, hematocrit, and infection risk, but laboratory evaluation is not an immediate life-saving intervention. It is secondary to airway assessment and stabilization.