The nurse is caring for a client who develops signs and symp... | HESI RN EXIT (IX)

Practice Question

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Answer Choices:

A. Monitor blood glucose level. ✓ Correct Answer

B. Maintain strict intake and output.

C. Assess warmth of extremities.

D. Keep head of bed raised 45 degrees.

Correct Answer:

Monitor blood glucose level.

Rationale:

✏️ In septic shock, stress-induced hyperglycemia is common, and blood glucose monitoring is vital to avoid complications like impaired immunity and delayed healing.

✏️High glucose levels worsen outcomes by fueling inflammatory cascades and bacterial growth.

✏️Blood glucose monitoring is part of evidence-based sepsis protocols, such as Surviving Sepsis Campaign guidelines.

✏️Tight glycemic control reduces the risk of organ failure and mortality in septic patients.

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Answer Choices:

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Question Details

Category: RN - Nursing Exam(s)
Subcategory: Exit Exams
Domain: HESI Exit - RN
Answer Choices: 4

NursingSprint

Practice Question

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer:

Rationale:

Want to practice more questions like this?

More Practice Questions

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

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Practice Question

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer:

Rationale:

Want to practice more questions like this?

More Practice Questions

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

From Exam

HESI RN EXIT (IX)

Question Details

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