A client had a bowel resection 5 days ago. The nurse assesses the client and finds that the client's temperature is 103 degrees F, pulse is 88, respirations are 20, and the blood pressure is 146/72. Urine output has been 160cc for the last 4 hours. The incision is erythemic and warm to touch. The nurse determines that the client's fever is most likely due to what condition?

Wound infection

Urinary tract infection

Respiratory infection

Dehydration

Answer and Explanation

The Correct Answer is A

A.   The combination of fever, tachycardia, decreased urine output, and erythema and warmth at the incision site suggests the possibility of a wound infection.
B.   While a urinary tract infection could cause fever and decreased urine output, the presence of erythema and warmth at the incision site suggests a localized wound infection.
C.   Respiratory infection may cause fever and tachycardia but would not typically present with erythema and warmth at the incision site.
D.   Dehydration may cause decreased urine output but would not typically present with fever and erythema at the incision site.

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Correct Answer is ["50"]

Explanation

To calculate the infusion rate in gtts/min, the nurse should use the following formula: Infusion rate (gtts/min) = Volume (mL) x Drop factor (gtts/mL) / Time (min) Plugging in the given values, we get:

Infusion rate (gtts/min) = 400 mL x 60 gtt/mL / 480 min Simplifying, we get:

Infusion rate (gtts/min) = 50 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 50 gtts/min.

A. the presence and extent of lymph node involvement B. the tissue or cell of origin C. the amount of differentiation of the cells D. tumor obstruction

Correct Answer is A

Explanation

A. The N in the TNM classification system stands for lymph node involvement, providing information on the presence and extent of lymph node involvement by the tumor.
B. The tissue or cell of origin is typically denoted by the primary tumor classification.

C. The amount of differentiation of the cells is usually described separately and not specifically represented by the N in the TNM system.
D. Tumor obstruction is not directly assessed by the N component of the TNM system.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 400 mL of 0.9% sodium chloride IV over 8 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtts/min? Label your answer.

Correct Answer is ["50"]

Explanation

Tumor staging includes the TNM classification system. The N in TNM would give the physician information on which part of the tumor classification?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include?

A nurse is caring for a client who has a wound infection. Wound cultures identify the infecting organism as vancomycin-resistant enterococci (VRE). Which type of precautions should the health care team initiate?

The nurse is caring for a client who was diagnosed with "gouty arthritis." Which laboratory test is most important to perform to confirm this diagnosis?

A client has been diagnosed with mumps as a child, the nurse concluded the client has which type of immunity?

A nurse is assigned to the following four clients with infections. The nurse realizes that which client has acquired a hospital-acquired infection?

The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

A client had a right knee replaced 4 days ago. The client returns with an elevated temperature for the past 24 hours. Which assessment would the nurse prioritize?