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: This is incorrect because standing directly in front of the client is not the priority action by the nurse when admitting a client who has a partial hearing loss. Standing directly in front of the client can enhance communication, but it is not as important as assessing the client's hearing status and needs.
Choice B Reason: This is incorrect because rephrasing statements the client does not hear is not the priority action by the nurse when admitting a client who has a partial hearing loss. Rephrasing statements can improve understanding, but it is not as essential as evaluating the client's hearing level and preferences.
Choice C Reason: This is incorrect because speaking using his usual tone of voice is not the priority action by the nurse when admitting a client who has a partial hearing loss. Speaking using his usual tone of voice may or may not be appropriate, depending on the client's hearing ability and comfort. The nurse should adjust his tone of voice based on the client's feedback and response.
Choice D Reason: This is the correct choice because determining if the client uses hearing aids is the priority action by the nurse when admitting a client who has a partial hearing loss. Hearing aids are devices that amplify sound and improve hearing for people with hearing loss. The nurse should determine if the client uses hearing aids, and if so, check their function, fit, and battery life. The nurse should also ask about any other assistive devices or strategies that the client uses to communicate effectively.
Correct Answer is D
Explanation
Choice A Reason: To administer medications and electrolytes is not the best reply for why the client will need the NG tube, because this is not the primary purpose of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Medications and electrolytes can be given through the IV route.
Choice B Reason: To dilate the stomach as a presurgical preparation is not the best reply for why the client will need the NG tube, because this is not a valid indication for the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Dilation of the stomach is not a goal of presurgical preparation, but rather an adverse effect of gastric obstruction.
Choice C Reason: You will not be able to eat for several days is not the best reply for why the client will need the NG tube, because this is not a complete or accurate explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. The client will not be able to eat for several days because of the NPO diet, which is necessary to rest the inflamed peritoneum and reduce the risk of complications.
Choice D Reason: To remove secretions and decompress your stomach is the best reply for why the client will need the NG tube, because this is a clear and correct explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration, which are common symptoms of acute peritonitis. By removing secretions and decompressing the stomach, the NG tube can reduce pain, inflammation, and infection in the abdominal cavity.
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