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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Colorectal cancer is not likely to cause nausea with projectile vomiting or high-pitched sounds in the left upper quadrant. Colorectal cancer may cause symptoms such as rectal bleeding, change in bowel habits, abdominal pain, or weight loss.
Choice B Reason: Paralytic ileus is a condition where the bowel stops working and does not contract or move food along. Paralytic ileus may cause symptoms such as abdominal distension, absence of bowel sounds, constipation, or vomiting.
Choice C Reason: Large bowel obstruction is a blockage of the colon or rectum that prevents the passage of stool. Large bowel obstruction may cause symptoms such as abdominal distension, low-pitched sounds in the right lower quadrant, constipation, or ribbon-like stools.
Choice D Reason: Small bowel obstruction is a blockage of the small intestine that prevents the passage of food and fluids. Small bowel obstruction may cause symptoms such as nausea with projectile vomiting, high-pitched sounds in the left upper quadrant, abdominal cramps, or dehydration.
Correct Answer is A
Explanation
Choice A Reason: Sweating and pallor are early signs and symptoms of dumping syndrome, which is a condition where food moves too quickly from the stomach to the small intestine, causing rapid fluid shifts and hormonal changes. Sweating and pallor are caused by hypoglycemia, which occurs when the high concentration of food in the small intestine stimulates insulin secretion.
Choice B Reason: Abdominal cramping and pain are late signs and symptoms of dumping syndrome, which occur about one to three hours after eating. Abdominal cramping and pain are caused by intestinal distension, spasms, and gas formation.
Choice C Reason: Double vision and chest pain are not signs and symptoms of dumping syndrome, but may indicate other serious conditions, such as stroke or heart attack. Double vision and chest pain should be reported to the provider immediately.
Choice D Reason: Bradycardia and indigestion are not signs and symptoms of dumping syndrome, but may be related to other gastrointestinal disorders, such as gastritis or peptic ulcer disease. Bradycardia and indigestion should be evaluated by the provider for further diagnosis and treatment.
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