A client receiving parenteral nutrition by central venous access reports feeling unwell. The nurse assesses the client and suspects that the central line has become infected. Which of the following findings indicate that the client has developed a systemic infection? Select all that apply.

Edema

Purulent drainage at intravenous insertion site

Redness at insertion site

Nausea

Leukocytosis

Fever

Answer and Explanation

Correct Answer : B,E,F

Choice A Reason: Edema is not a specific finding of a systemic infection, but rather a possible sign of fluid overload or impaired venous return. It can occur due to excessive infusion rate, heart failure, or obstruction of blood flow in or around the central line.

Choice B Reason: This is a correct choice. Purulent drainage at intravenous insertion site is a finding of a local infection that can spread systemically. It indicates bacterial invasion and inflammation of the skin and subcutaneous tissue around the catheter.

Choice C Reason: Redness at insertion site is a finding of a local infection that can spread systemically. It indicates increased blood flow and inflammation of the skin and subcutaneous tissue around the catheter.

Choice D Reason: Nausea is not a specific finding of a systemic infection, but rather a possible side effect of parenteral nutrition or a symptom of another condition. It can occur due to electrolyte imbalance, hyperglycemia, or gastrointestinal disorders.

Choice E Reason: This is a correct choice. Leukocytosis is a finding of a systemic infection that indicates increased production and release of white blood cells in response to infection. It can be detected by a blood test.

Choice F Reason: This is a correct choice. Fever is a finding of a systemic infection that indicates increased body temperature due to activation of the immune system and release of pyrogens. It can be measured by a thermometer.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.

Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.

Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.

Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.

A. Cranial Nerve VIII B. Cranial Nerve II C. Cranial Nerve I D. Cranial Nerve VII

Correct Answer is B

Explanation

Choice A Reason: This choice is incorrect. Cranial Nerve VIII is the vestibulocochlear nerve, which is responsible for hearing and balance. It does not affect vision or eye movements.

Choice B Reason: This is the correct choice. Cranial Nerve II is the optic nerve, which is responsible for transmitting visual information from the retina to the brain. It affects visual field and visual acuity, which are measures of peripheral and central vision, respectively.

Choice C Reason: This choice is incorrect. Cranial Nerve I is the olfactory nerve, which is responsible for smell. It does not affect vision or eye movements.

Choice D Reason: This choice is incorrect. Cranial Nerve VII is the facial nerve, which is responsible for facial expressions and taste. It does not affect vision or eye movements.

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 receiving parenteral nutrition by central venous access reports feeling unwell. The nurse assesses the client and suspects that the central line has become infected. Which of the following findings indicate that the client has developed a systemic infection? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

It is night time and a client who suffers from dementia is agitated and is having difficulty staying in his bed. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is performing a focused assessment for vision on a client suspected of having vision loss. Which cranial nerve is the nurse assessing when determining if there are visual field or visual acuity deficits?

Correct Answer is B

Explanation

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include?

A client diagnosed with moderate Alzheimer's has been admitted to a long-term care facility. Which of the following are appropriate activities for the nurse to include in the care plan?

A nurse is preparing a client with extensive burns for hydrotherapy. What is the priority action by the nurse?

When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. Which of the following findings is consistent with manifestations of cataracts?

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

When performing an assessment, the nurse observes for bilateral equality. After performing a neurological assessment, which of the following will the nurse document when assessment findings indicate that there is left facial droop?

A client diagnosed with contact dermatitis is receiving education from the nurse. Which of the following therapies will the nurse recommend to the client?