A nurse is caring for a client who has an infected surgical wound on his abdomen. The nurse notes that the wound has redness, warmth, swelling, pain, and purulent drainage. The nurse recognizes these findings as indicative of what stage of inflammation?

Vascular stage

Cellular stage

Exudative stage

Resolution stage

Answer and Explanation

The Correct Answer is C

Choice A reason:

Vascular stage is the stage of inflammation that involves the changes in blood flow and vascular permeability at the site of injury or infection. It manifests as redness and warmth due to vasodilation and increased blood flow, and swelling due to fluid leakage from the vessels into the interstitial space.

Choice B reason:

Cellular stage is the stage of inflammation that involves the migration of white blood cells from the vessels into the tissues to eliminate the causative agent and remove the damaged tissue. It manifests as pain due to the release of chemical mediators that stimulate nerve endings, and purulent drainage due to the accumulation of dead cells and microorganisms.

Choice D reason:

Resolution stage is the stage of inflammation that involves the restoration of normal tissue structure and function after the elimination of the causative agent and the removal of the damaged tissue. It manifests as decreased redness, warmth, swelling, pain, and drainage due to the cessation of inflammatory response.

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Correct Answer is A

Explanation

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.

A. Restrict fluid intake B. Monitor neurological status C. Administer hypotonic IV fluids D. Encourage foods high in sodium E. Provide oral hygiene frequently

Correct Answer is ["B","C","E"]

Explanation

Choice A reason:

Restricting fluid intake is not an action that the nurse should take for a client who has hypernatremia. Fluid restriction can worsen hypernatremia by increasing the concentration of sodium in the blood. Fluid intake should be increased or replaced with isotonic or hypotonic fluids to dilute sodium and correct hypernatremia.

Choice B reason:

Monitoring neurological status is an action that the nurse should take for a client who has hypernatremia. Hypernatremia can cause neurological symptoms such as confusion, agitation, seizures, coma, and death due to cellular dehydration and brain shrinkage. The nurse should assess the client's level of consciousness, orientation, memory, behavior, and reflexes regularly and report any changes or deterioration.

Choice C reason:

Administering hypotonic IV fluids is an action that the nurse should take for a client who has hypernatremia. Hypotonic fluids have a lower concentration of solutes than normal body fluids and can help lower serum sodium levels by moving water into the cells from the blood vessels. The nurse should administer hypotonic fluids slowly and carefully to avoid fluid overload or cerebral edema.

Choice D reason:

Encouraging foods high in sodium is not an action that the nurse should take for a client who has hypernat

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A nurse is caring for a client who has an infected surgical wound on his abdomen. The nurse notes that the wound has redness, warmth, swelling, pain, and purulent drainage. The nurse recognizes these findings as indicative of what stage of inflammation?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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