A nurse is caring for a client who has pleural effusion and has undergone thoracentesis.
The nurse should identify which of the following findings as indicative of an infection?
Milky fluid.
Bloody fluid.
Viscous fluid.
Purulent fluid.
The Correct Answer is D
Choice A rationale
Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.
Choice B rationale
Bloody fluid may indicate trauma or malignancy but not necessarily infection.
Choice C rationale
Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.
Choice D rationale
Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
Obtaining a wound culture is crucial to identify the causative organism and guide appropriate antibiotic therapy. Prompt identification and treatment of the infection source can prevent further systemic complications.
Choice B rationale:
Rapidly administering 30 mL/kg of normal saline helps to restore intravascular volume, improve hemodynamic stability, and enhance tissue perfusion. This intervention is vital in the initial management of sepsis to prevent organ dysfunction.
Choice D rationale:
Obtaining blood cultures before initiating antibiotic therapy is essential to identify the causative microorganism and tailor antibiotic treatment. This step ensures accurate diagnosis and effective management of sepsis.
Choice E rationale:
Administering broad-spectrum antibiotics as soon as possible is critical in managing sepsis. Early and appropriate antibiotic therapy significantly reduces mortality and morbidity by targeting the suspected pathogens promptly.
Correct Answer is A
Explanation
Choice A rationale
Obtaining a prescription for supplemental oxygen is the first action as hypoxia must be corrected immediately to ensure adequate tissue oxygenation.
Choice B rationale
Obtaining a prescription to administer intravenous fluids is essential to address dehydration but is secondary to correcting hypoxia.
Choice C rationale
Obtaining a prescription to administer insulin is crucial to manage hyperglycemia in diabetic ketoacidosis but not the initial step in this context.
Choice D rationale
Obtaining a prescription to check the client's glucose level is necessary for monitoring but does not address the immediate need for oxygenation.
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