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NEW QUESTION: 1
A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder). Based on this diagnosis, all the following are appropriate entries in the nursing care plan except:
A. obtain an order for a stool softener.
B. administer packed RBCs, if ordered.
C. encourage the client to rinse her mouth with mouthwash and scrub her teeth with an oral sponge.
D. dress venipuncture sites immediately to prevent infection.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
Firm, direct pressure should be applied to venipuncture sites for 3-7 minutes before final dressing because of the clotting abnormality. Septic shock is a systemic infection of the bloodstream producing clinical manifestations - warm, flushed skin; high urine output; tachycardia; edema; respiratory problems; restlessness; altered level of consciousness; life-threatening form of shock. Physiological Adaptation