A nurse is assessing a client who has septic shock. The nurse notes that the client has a blood pressure of 80/50 mmHg, a heart rate of 120 beats per minute, a respiratory rate of 28 breaths per minute, and a temperature of 39°C.

The nurse calculates that the client has a Sequential Organ Failure Assessment (SOFA) score of what value?

Provide supplemental oxygen as needed

Answer and Explanation

The Correct Answer is A

The SOFA score is a tool that assesses the degree of organ dysfunction or failure in septic shock. It is based on six parameters: blood pressure, Glasgow coma scale, PaO2/FiO2 ratio, platelet count, bilirubin level, and creatinine level. Each parameter is assigned a score from 0 to 4 based on the severity of the abnormality. The total SOFA score ranges from 0 to 24, with higher scores indicating worse organ dysfunction or failure.

The client's blood pressure of 80/50 mmHg corresponds to a SOFA score of 1, as it indicates hypotension.

The client's Glasgow coma scale is not given, so it is assumed to be normal (15), which corresponds to a SOFA score of 0.

The client's PaO2/FiO2 ratio is not given, so it is assumed to be normal (>400), which corresponds to a SOFA score of 0.

The client's platelet count is not given, so it is assumed to be normal (>150 x 10^9/L), which corresponds to a SOFA score of 0.

The client's bilirubin level is not given, so it is assumed to be normal (<20 micromol/L), which corresponds to a SOFA score of 0.

The client's creatinine level is not given, so it is assumed to be normal (<110 micromol/L), which corresponds to a SOFA score of 0.

The total SOFA score is the sum of the scores for each parameter: 1 + 0 + 0 + 0 + 0 + 0 = 1. Therefore, the client has a SOFA score of 1.

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Correct Answer is C

Explanation

Choice A reason:

This is an incorrect answer because cardiogenic shock is a severe form of heart failure that occurs when the heart cannot pump enough blood to maintain adequate tissue perfusion and oxygenation, resulting in hypotension, tachycardia, oliguria, altered mental status, and cold and clammy skin.

Choice B reason:

This is an incorrect answer because pulmonary embolism is a condition in which a blood clot travels to the lungs and blocks one or more pulmonary arteries, causing sudden dyspnea, chest pain, hemoptysis, tachypnea, and hypoxia.

Choice C reason:

This is a correct answer because right-sided heart failure occurs when the right ventricle of the heart fails to pump blood effectively to the lungs, causing blood to back up in the systemic circulation and leading to fluid accumulation in the lungs, neck veins, and extremities.

Choice D reason:

This is an incorrect answer because left-sided heart failure occurs when the left ventricle of the heart fails to pump blood effectively to the body, causing blood to back up in the pulmonary circulation and leading to pulmonary congestion, dyspnea, orthopnea, coughing, and fatigue.

A. B cells B. T cells C. T cells D. Mast cells

Correct Answer is B

Explanation

Choice A reason:

B cells are not involved in contact dermatitis, as they do not produce antibodies or form immune complexes.

Choice B reason:

T cells are the type of cells that mediate contact dermatitis, which is a type of type IV hypersensitivity. T cells recognize the poison ivy antigens that bind to the skin proteins and release cytokines that recruit macrophages and other inflammatory cells. This leads to a delayed and localized reaction that manifests as erythema, edema, vesicles, and pruritus.

Choice C reason:

T cells are not the same as B cells, as they have different receptors and functions in the immune system.

Choice D reason:

Mast cells are not involved in contact dermatitis, as they do not express IgE antibodies or release histamine.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who has contact dermatitis after exposure to poison ivy. The nurse recognizes that this condition is mediated by what type of cells?

Correct Answer is B

Explanation

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