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 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.

A. Let me inform you about the care you’ll receive post-surgery and the level of pain you can expect. B. If it’s any consolation, everyone feels nervous before surgery. C. Can you share with me what you’ve been informed about your surgery? D. I would be glad to explain the entire surgical procedure to you.

Correct Answer is C

Explanation

Choice A rationale:
While providing information about post-operative care and pain management is important, it may not directly address the patient's underlying anxiety or encourage them to express their concerns.
It could be perceived as dismissive of their feelings or as an attempt to control the conversation. It focuses on the future rather than the patient's present experience.
Choice B rationale:
This response, while intended to be reassuring, may minimize the patient's individual experience and feelings. It could make the patient feel as though their concerns are not being taken seriously.
It implies that anxiety is a normal and expected reaction, which may discourage the patient from sharing their specific worries.
Choice C rationale:
This response is open-ended and invites the patient to share their thoughts and feelings.
It demonstrates active listening and encourages the patient to take an active role in the conversation.
It allows the nurse to assess the patient's understanding of the surgery and to address any misconceptions or concerns. It conveys a sense of empathy and understanding, which can help to build trust and rapport with the patient.
Choice D rationale:
While offering to explain the procedure may be helpful, it may not be what the patient needs at the moment. It could overwhelm the patient with information, particularly if they are already feeling anxious.
It could shift the focus away from the patient's emotional needs and onto the technical aspects of the surgery.

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

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

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

A nurse is caring for an older patient admitted with mild dehydration. What advice should the nurse give to best address this issue?

A patient diagnosed with HIV-II is admitted to the hospital presenting symptoms of fever, night sweats, and a severe cough. The laboratory results show a CD4+ cell count of 180/mm and a negative tuberculosis (TB) skin test conducted 4 days prior. What is the first action the nurse should take?

A nurse working on the postoperative floor has four patients who are scheduled to be discharged tomorrow. Which patient has the greatest need for the nurse to consult with other members of the healthcare team regarding post-discharge care?

A patient diagnosed with HIV-II and wasting syndrome is suffering from inadequate nutrition. What assessment finding by the nurse would best indicate that the goals have been met for this patient’s problem?

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?

A nurse is discussing with a colleague who is relocating to a new state and needs to find a new job there. What is the best advice the nurse can give?

While assessing a patient who has just arrived from the Post Anesthesia Care Unit (PACU), the nurse hears stridor. What is the first action the nurse should take?