A nurse is assisting with the care of a preschooler who sustained a major burn injury 5 days ago. Which of the following findings should the nurse identify as a manifestation of sepsis?
Polyuria
Disorientation
Hyperactive bowel sounds
Hypoglycemia
The Correct Answer is B
A. Polyuria is not typically associated with sepsis; it may be seen in other conditions such as diabetes. In sepsis, urine output is often decreased due to impaired kidney function and shock.
B. Disorientation is a sign of sepsis, indicating that the infection may have spread to the bloodstream and is affecting the central nervous system. Altered mental status is a critical indicator of severe infection.
C. Hyperactive bowel sounds are not associated with sepsis. In sepsis, bowel sounds may actually be decreased due to decreased perfusion to the gastrointestinal tract.
D. Hypoglycemia can occur in sepsis, but it is not as specific an indicator as disorientation. Monitoring blood glucose levels is important, but disorientation provides a clearer sign of systemic infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instilling 2 mL of 0.9% sodium chloride is not recommended as it can cause discomfort and does not improve the effectiveness of suctioning.
B. Sterile technique, not clean technique, should be used when suctioning a tracheostomy to prevent infection.
C. Applying suction in 3 to 4 second increments is appropriate to clear the occlusion effectively without causing trauma to the trachea.
D. The catheter should not fit snugly into the tracheostomy tube; it should be small enough to fit comfortably to avoid trauma and ensure effective suctioning.
Correct Answer is []
Explanation
Condition:
Pyelonephritis: The presence of fever, frequent and painful urination, and costovertebral angle tenderness, along with the urinalysis findings (cloudy urine, leukocyte esterase, nitrites, WBCs) and elevated WBC count suggest an upper urinary tract infection, likely pyelonephritis.
Actions to Take:
Request prescription for antibiotics: Pyelonephritis is a bacterial infection that requires antibiotic treatment to prevent complications and resolve the infection.
Encourage increased fluid intake: This helps to flush bacteria from the urinary tract, reducing the concentration of bacteria in the urine and helping to relieve symptoms.
Parameters to Monitor:
Child’s report of urgency: This can help assess if the infection is affecting the lower urinary tract as well and track the effectiveness of treatment.
Urine odor: Foul-smelling urine can indicate ongoing infection or bacterial presence and can be an indicator of the effectiveness of the treatment.
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