A client is admitted with possible sepsis. Which action will the nurse perform first?

Administer an antipyretic.

Obtain specified cultures.

Administer antibiotics.

Place the client in isolation.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Administering an antipyretic would lower the client's fever, but it would not address the underlying cause of the sepsis. Antipyretics can mask important signs and symptoms of infection, making it more difficult to diagnose and treat the sepsis. It's important to identify the causative organism of sepsis to initiate appropriate antibiotic therapy.
Therefore, obtaining cultures to identify the causative organism is the priority action.
Choice B rationale:
Obtaining specified cultures is the most important action for a client with possible sepsis because it allows for the identification of the causative organism.
This information is essential for selecting the appropriate antibiotic therapy. Cultures should be obtained as soon as possible, before antibiotics are administered.
Choice C rationale:
While administering antibiotics is an important part of the treatment for sepsis, it is not the first action that the nurse should take.
Antibiotics should be administered after the causative organism has been identified.
Administering antibiotics before cultures are obtained can make it more difficult to identify the causative organism.
Choice D rationale:
Placing the client in isolation is important to prevent the spread of infection, but it is not the first action that the nurse should take.
The priority is to identify the causative organism and initiate appropriate treatment. The client can be placed in isolation after cultures have been obtained.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:
A serum sodium level of 134 mEq/L (134 mmol/L) is mildly low, but this level of hyponatremia is not typically associated with significant cognitive impairment.
Symptoms of hyponatremia, such as confusion, lethargy, and seizures, usually occur when sodium levels are 125 mEq/L or lower.
However, it's important to monitor this patient for any changes in cognitive status as hyponatremia can worsen and lead to more severe symptoms.
Choice C rationale:
A patient who underwent an open cholecystectomy two days ago may experience some cognitive impairment due to the effects of anesthesia and pain medications.
However, this type of impairment is usually temporary and resolves within a few days.
It's important to assess for cognitive impairment in this patient, but it is not the most urgent priority.
Choice D rationale:
A 32-year-old patient with a 20-pack-year history of smoking is at risk for cognitive impairment due to the long-term effects of smoking on the brain.
However, this risk is typically not as immediate as the risk of cognitive impairment following a stroke.
It's important to educate this patient about the risks of smoking and encourage smoking cessation, but it is not the most urgent priority in terms of cognitive assessment.
Choice B rationale:
An 88-year-old patient who had a hemorrhagic stroke three days ago is at the highest risk for cognitive impairment among the given options.
Hemorrhagic stroke involves bleeding in the brain, which can damage brain tissue and lead to cognitive deficits.
The risk of cognitive impairment is particularly high in older adults, as they may have less cognitive reserve to compensate for the damage caused by the stroke.
Early assessment and intervention for cognitive impairment are crucial for optimizing recovery and quality of life in stroke patients.
Prompt evaluation for cognitive impairment is essential to identify any deficits and initiate appropriate interventions to support the patient's cognitive function and recovery.

A. “It will reduce the risk of receiving white blood cells from the donor that could impair the function of your transplanted kidney.” B. “All pre-transplant patients receive leukocyte-poor blood because it is better absorbed by the body.” C. “It causes fewer blood reactions in pre-transplant patients.” D. “It is less likely to cause hemolysis, or destruction of the blood cells, after transfusion.”

Correct Answer is A

Explanation

Choice A rationale:
Leukocyte-poor packed red blood cells (LP-PRBCs) have a significantly reduced number of white blood cells (WBCs), also known as leukocytes. This is crucial for pre-transplant patients like the one in the question for several reasons:
Prevention of Alloimmunization: WBCs in blood transfusions carry human leukocyte antigens (HLAs), which are proteins on the surface of cells that play a role in the immune system. Exposure to foreign HLAs can cause the recipient's immune system to develop antibodies against them, a process called alloimmunization. These antibodies can then attack and damage the transplanted kidney, leading to rejection. By reducing the number of WBCs in the transfusion, LP-PRBCs significantly lower the risk of alloimmunization.
Reduced Incidence of Febrile Non-Hemolytic Transfusion Reactions (FNHTRs): FNHTRs are the most common type of transfusion reaction, characterized by fever, chills, and occasionally other symptoms like nausea and vomiting. They are thought to be caused by cytokines released from WBCs in the transfused blood. LP-PRBCs, with their reduced WBC content, have been shown to lower the incidence of FNHTRs.
Potential Benefits for Graft Survival: Some studies have suggested that the use of LP-PRBCs for transfusions may improve long-term graft survival rates in kidney transplant patients, although more research is needed to confirm these findings.
Choice B rationale:
This statement is incorrect. While LP-PRBCs may have some advantages in terms of absorption or utilization, this is not the primary reason for their use in pre-transplant patients. The main goal is to reduce the risk of alloimmunization and other transfusion-related complications.
Choice C rationale:
This statement is partially correct. LP-PRBCs do tend to cause fewer blood reactions, particularly FNHTRs, as explained in the rationale for Choice A. However, this is not the most comprehensive or accurate explanation for their use in pre-transplant patients.
Choice D rationale:
This statement is not directly relevant to the use of LP-PRBCs in pre-transplant patients. While LP-PRBCs may have a lower risk of hemolysis, this is not the primary reason for their use in this specific context.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is admitted with possible sepsis. Which action will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for four patients. Which patient should the nurse evaluate first for cognitive impairment?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

A nurse is learning the difference between normal cells and benign tumor cells. What information does this include?

A patient about to undergo surgery is expressing anxiety. Which nurse’s response is most likely to encourage further conversation with the patient?

A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority nursing diagnosis have been met?

A nurse learns that which of the following is the single biggest risk factor for developing cancer?

A nurse is providing care for a patient suffering from severe diarrhea. Which acid-base disorder is the patient at risk of developing?

A nursing manager is worried about the number of infections in the hospital unit. What action by the manager would be most effective in preventing these infections?

A nurse is evaluating patients who have been prescribed intravenous therapy. Which observation for a patient with a Peripherally Inserted Central Catheter (PICC) demands immediate attention?

The nurse is reviewing a client’s laboratory results and notes the serum potassium level is 2.8 mEq/L. Which nursing action should be initiated immediately?