A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care?

A. Maintain strict intake and output: In septic shock, monitoring fluid balance is critical because clients are at high risk for hypovolemia, organ dysfunction, and multi-organ failure. Accurate intake and output measurements guide fluid resuscitation and help evaluate response to therapy. B. Monitor blood glucose level: Hyperglycemia can occur in sepsis and should be monitored, but it is secondary to maintaining adequate perfusion and fluid balance. Glucose monitoring supports overall care but is not the immediate priority in shock management. C. Assess warmth of extremities: Extremity warmth or coolness provides information about perfusion and circulatory status but is observational. It does not actively intervene to reverse the pathophysiologic processes of septic shock. D. Keep head of bed raised 45 degrees: Elevating the head of the bed may reduce aspiration risk, but it does not address the urgent need to manage hypoperfusion, organ perfusion, and fluid status in septic shock.