A client with peritonitis presents with an elevated temperature, rapid heart rate, and shallow breathing. The nurse recognizes these signs as indicative of:
Hypothermia
Hypertension
Hyperventilation
Systemic inflammatory response
The Correct Answer is D
Choice A reason:
Hypothermia refers to abnormally low body temperature and is not associated with the clinical presentation of peritonitis.
Choice B reason:
Hypertension refers to high blood pressure and is not directly associated with the signs of peritonitis.
Choice C reason:
Hyperventilation involves rapid breathing but may not always be present in peritonitis.
Choice D reason:
The client's elevated temperature, rapid heart rate, and shallow breathing are indicative of a systemic inflammatory response, which is a characteristic feature of peritonitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Administering oral antibiotics may be necessary for treating the wound infection, but it does not directly prevent the spread of infection.
Choice B reason:
Performing sterile dressing changes is essential in preventing the spread of infection and promoting wound healing.
Choice C reason:
Limiting visitors to the client's room may help reduce the risk of introducing new pathogens, but it is not the primary intervention for preventing wound infection.
Choice D reason:
Providing pain medication as needed is important for the client's comfort but does not directly prevent the spread of infection.
Correct Answer is A
Explanation
Choice A reason:
Administering oxygen as prescribed is the priority intervention in managing acute respiratory distress to improve oxygenation and support respiratory function.
Choice B reason:
Elevating the head of the bed is helpful for promoting lung expansion, but it is not the priority intervention in managing acute respiratory distress.
Choice C reason:
Monitoring blood pressure regularly is essential in assessing the client's overall condition, but it does not directly address the respiratory distress.
Choice D reason:
Administering bronchodilator medication is not the priority intervention in managing acute respiratory distress unless there is a specific indication for its use.
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