A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
Localized edema.
An increase in neutrophils.
An increase in platelets.
Bradycardia.
An increase in RBCS.
Correct Answer : A,B
Choice A rationale:
Localized edema is a common sign of infection. The body sends extra fluid to the area as part of the inflammatory response.
Choice B rationale:
An increase in neutrophils, a type of white blood cell, is a common response to infection. Neutrophils are part of the body’s immune response and work to fight off invading bacteria.
Choice C rationale:
An increase in platelets is not typically associated with infection. Platelets are involved in blood clotting, not the immune response.
Choice D rationale:
Bradycardia, or a slow heart rate, is not typically associated with infection. Infection usually causes an increased heart rate, not a decreased one.
Choice E rationale:
An increase in RBCs is not typically associated with infection. RBCs carry oxygen around the body, but their number does not usually change in response to infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Examining feet daily is important for preventing complications related to peripheral neuropathy, not retinopathy or nephropathy.
Choice B rationale:
Maintaining stable blood glucose levels can help prevent microvascular complications such as retinopathy and nephropathy.
Choice C rationale:
Annual eye examinations are important, but they do not prevent retinopathy.
Choice D rationale:
Wearing compression stockings daily is not directly related to preventing retinopathy or nephropathy.
Correct Answer is C
Explanation
Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.
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