The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.)
a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
ANS: A, C, D, E
Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.
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The care plan for a child with disseminated intravascular coagulation (DIC) includes:
a. hospitalization at the first sign of bleeding. b. teaching the child relaxation techniques for pain control. c. management in the intensive care unit. d. provision of adequate hydration to prevent complications.