A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)
A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min.
A client who has a heart rate of 132/min and a respiratory rate of 30/min.
A client who has a decrease in level of consciousness and a heart rate greater than 130/min.
A client who has bradypnea and a white blood cell (WBC) count of 10,000/mm³ (normal range: 5,000 to 10,000/mm³).
A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min.
Correct Answer : B,C
Choice A reason:
A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.
Choice B reason:
A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.
Choice C reason:
A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.
Choice D reason:
Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm³ is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.
Choice E reason:
A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Hyperplasia is an increase in the number of cells in an organ or tissue, which can lead to its enlargement. While hyperplasia can be a response to a stimulus and is not necessarily precancerous, it does not describe the abnormal changes in the shape, size, and organization of mature cells.
Choice B reason:
Metaplasia is a reversible change in which one differentiated cell type is replaced by another cell type. This process can be a response to chronic irritation and inflammation, and while it may predispose cells to cancerous changes, it is not in itself a precancerous condition.
Choice C reason:
The term 'malignant' refers to cancerous cells that have the ability to invade and destroy nearby tissue and spread to other parts of the body. The description of the cells as 'moderately abnormal' does not indicate that the cells are malignant but rather that they are showing signs of potentially precancerous changes.
Choice D reason:
Dysplasia refers to the presence of abnormal cells within a tissue or organ. It is characterized by changes in cell size, shape, uniformity, arrangement, and structure, particularly when such changes are strongly suggestive of developing neoplasia, or new, abnormal growth. In the context of a Pap smear, dysplasia is indicative of precancerous changes and is the term used to describe the abnormal development of cells on the cervix.
Correct Answer is A
Explanation
Choice A reason: Drink 3L of fluid every day
Drinking adequate fluids, especially water, is one of the most effective ways to prevent kidney stones. Fluids dilute the substances in urine that lead to stones. For someone with a history of kidney stones, drinking about 3 liters of water each day can help prevent stone formation¹².
Choice B reason: Take 3,000 mg of vitamin C daily
High doses of vitamin C can increase the risk of kidney stones as the body converts vitamin C into oxalate, which can then form stones. Therefore, taking 3,000 mg of vitamin C daily is not recommended for individuals prone to calcium oxalate stones².
Choice C reason: Restrict calcium intake to one serving per day
Contrary to what might seem intuitive, restricting calcium intake is not generally advised for preventing calcium oxalate stones. Adequate dietary calcium can help reduce the amount of oxalate being absorbed by the body, thus lowering the risk of stone formation. It's important to consume calcium-rich foods in moderation and not to restrict them severely.
Choice D reason: Eat 12 oz of animal protein daily
A high intake of animal protein can increase the risk of kidney stones in susceptible individuals. Animal protein can increase calcium and oxalate levels in urine and reduce levels of citrate, a substance that prevents stones. Therefore, it's recommended to limit animal protein intake rather than consume large amounts.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today