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A client is recovering from an open reduction of the femur suddenly feels light headed, with increased anxiety and agitation. Which key vital sign differentiates early sepsis from a pulmonary embolism?

Tachycardia

Hypotension

Tachypnea

Increased temperature

Answer and Explanation

The Correct Answer is D

A. Tachycardia: Present in both early sepsis and PE, so it does not differentiate them.

B. Hypotension: Common in later stages of sepsis and PE, not an early differentiating sign.

C. Tachypnea: Seen in both conditions, so it is not a distinguishing feature.

D. Increased temperature: Fever is an early sign of sepsis, differentiating it from pulmonary embolism (PE), which is more likely associated with acute respiratory distress, tachycardia, and chest pain.

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Correct Answer is A

Explanation

A. Prepare for a STAT non-contrast CT scan: After a traumatic fall, a non-contrast CT scan is critical to assess for internal injuries such as brain hemorrhage or spinal trauma.

B. Perform a thorough health history: History is essential but secondary to identifying life-threatening conditions.

C. Insert an indwelling urinary catheter: This is appropriate for monitoring output but not a priority before imaging.

D. Administer acetaminophen by mouth for pain control: Pain management is secondary to identifying life-threatening injuries.

A. Remove clothing for a thorough assessment. B. Perform a Glasgow Coma Scale assessment. C. Open the airway using a jaw-thrust maneuver. D. Determine effectiveness of ventilator efforts. E. Establish IV access.

Correct Answer is C,D,E,B,A

Explanation

The primary survey follows the ABCDE framework:

Airway: Open the airway immediately using the jaw-thrust maneuver to avoid spinal injury.
Breathing: Assess ventilatory efforts to ensure adequate oxygenation.
Circulation: Establish IV access for fluid resuscitation and medication.
Disability: Perform neurological assessment using the Glasgow Coma Scale.
Exposure: Remove clothing to assess injuries fully.

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A client is recovering from an open reduction of the femur suddenly feels light headed, with increased anxiety and agitation. Which key vital sign differentiates early sepsis from a pulmonary embolism?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?

Correct Answer is A

Explanation

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,D,E,B,A

Explanation

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The nurse is providing care for a patient that is scheduled for a balloon valvuloplasty. The nurse recalls that balloon valvuloplasty is most commonly used for which valvular heart disease?

A client is recovering from an open reduction of the femur suddenly feels light headed, with increased anxiety and agitation. Which key vital sign differentiates early sepsis from a pulmonary embolism?

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