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. Keep head of bed raised 45 degrees. B. Maintain strict intake and output. C. Monitor blood glucose level. D. Assess warmth of extremities. iim stuck between B and D.