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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:
Restricting the client's oral fluid intake is not typically recommended as part of postoperative care following TURP. In fact, maintaining adequate hydration is important to help flush the bladder and prevent clot formation.

Choice B reason:
It is common for clients to feel a constant urge to void due to the irritation of the bladder from the catheter and the continuous bladder irrigation. Reminding the client that this sensation is normal and expected can help alleviate anxiety and provide reassurance.

Choice C reason:
Monitoring the client's urine output is important to ensure that the bladder irrigation is effective and that there are no signs of obstruction. However, it should be done more frequently than every 6 hours, especially in the immediate postoperative period, to promptly detect any complications.

Choice D reason:
Weighing the client every evening is not directly related to the management of continuous bladder irrigation. While monitoring weight can be part of overall postoperative care, it does not address the specific needs related to TURP and continuous bladder irrigation.

A. The client is Black. B. The client has several sexual partners. C. The client is male. D. The client has sex with men. E. The client is 37 years old.

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

Explanation

Choice A reason:
The statement "The client is Black" does not contribute to the risk of chlamydia based on race alone. Chlamydia infection rates are influenced by a variety of factors, including access to healthcare and socioeconomic status, rather than race itself.

Choice B reason:
Having multiple sexual partners significantly increases the risk of contracting sexually transmitted infections (STIs) like chlamydia because it raises the likelihood of exposure to an infected partner.

Choice C reason:
While being male is not a risk factor in itself, men who have sex with men (MSM) are at a higher risk for STIs like chlamydia due to biological and behavioral factors that facilitate transmission.

Choice D reason:
Engaging in sexual activities with men is a known risk factor for chlamydia among MSM due to the higher prevalence of this STI within this group.

Choice E reason:
The age of 37 does not specifically contribute to the risk of chlamydia. However, chlamydia is more commonly diagnosed in younger individuals, typically those under 25 years old, due to higher rates of new and multiple sexual partnerships.

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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)

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Explanation

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