Nokea
Which nursing intervention is most important in preventing septic shock?
- A. Administering I.V. fluid replacement therapy as ordered.
- B. Obtaining vital signs every 4 hours for all clients.
- C. Monitoring red blood cell counts for elevation.
- D. Maintaining asepsis of indwelling urinary catheters.
Correct Answer: D
Rationale: Septic shock is often caused by infections from invasive devices like urinary catheters. Maintaining asepsis during catheter insertion and care is critical to prevent infection and subsequent septic shock. Fluid therapy, vital signs, and RBC monitoring are important but not primary for prevention.
You may also like to solve these questions
A client with rheumatoid arthritis states, 'I can't do my household chores without becoming tired. My knees hurt whenever I walk.' Which nursing diagnosis would be most appropriate?
- A. Activity intolerance related to fatigue and pain.
- B. Self-care deficit related to increasing joint pain.
- C. Selective coping related to chronic pain.
- D. Disturbed body image related to fatigue and joint pain.
Correct Answer: A
Rationale: The client's symptoms of fatigue and knee pain directly contribute to activity intolerance, making this the most appropriate nursing diagnosis.
Which of the following interventions would be the most appropriate for preventing the development of a paralytic ileus in a client who has undergone renal surgery?
- A. Encourage the client to ambulate every 2 to 4 hours.
- B. Offer 3 to 4 oz of a carbonated beverage periodically.
- C. Encourage use of a stool softener.
- D. Continue I.V. fluid therapy.
Correct Answer: A
Rationale: Ambulation stimulates bowel motility, reducing the risk of paralytic ileus post-renal surgery by promoting gastrointestinal function.
A 92-year-old male client who is independent and lives alone has an inguinal hernia repair. Which teaching method is the best approach to use for his postoperative and discharge instructions?
- A. Written instructions with diagrams.
- B. Verbal instructions with repetition.
- C. Demonstration and return demonstration.
- D. Video instructions with follow-up.
Correct Answer: C
Rationale: Demonstration and return demonstration is the most effective for an elderly client, as it ensures understanding and ability to perform postoperative care tasks, accommodating potential sensory or cognitive limitations.
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan?
- A. Restrict fluids to 1,000 mL/24 hours.
- B. Drink 400 to 500 mL with each meal.
- C. Drink fluids midmorning, midafternoon, and late afternoon.
- D. Attempt to void at least every 2 hours.
- E. Use intermittent catheterization as needed.
Correct Answer: B,C,D,E
Rationale: Drinking 400-500 mL with meals (B), timing fluids (C), voiding every 2 hours (D), and using intermittent catheterization (E) promote bladder control. Restricting fluids to 1,000 mL/day risks dehydration and is inappropriate.
Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal influenza vaccination?
- A. A 60-year-old man with a hiatal hernia.
- B. A 36-year-old woman with three children.
- C. A 50-year-old woman caring for a spouse with cancer.
- D. A 60-year-old woman with osteoarthritis.
Correct Answer: C
Rationale: The 50-year-old caring for an immunocompromised spouse is the highest priority for influenza vaccination to prevent transmission. Others have lower risk profiles.