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:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.
Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.
Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.
Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.
Correct Answer is B
Explanation
Choice A reason:
Antinuclear antibody (ANA) is a test used to help diagnose autoimmune disorders, including RA. However, ANA is not typically used to monitor the effectiveness of treatment with aspirin in RA. Aspirin is an anti-inflammatory medication, and its effectiveness would not be directly measured by changes in ANA levels.
Choice B reason:
Erythrocyte sedimentation rate (ESR) is a blood test that can detect inflammation in the body and is commonly used to assess the severity of inflammation in patients with RA. Aspirin can reduce inflammation, so a decrease in ESR can indicate the effectiveness of aspirin therapy in managing RA symptoms.
Choice C reason:
Rheumatoid factor (RF) is an antibody that can be present in the blood of people with RA. While RF can be used to help diagnose RA, it is not typically used to monitor the effectiveness of aspirin therapy. RF levels can remain elevated even when symptoms are well-controlled.
Choice D reason:
White blood cell (WBC) count is a measure of the body's immune response and can be elevated in cases of infection or inflammation. However, WBC count is not specifically used to monitor the effectiveness of aspirin therapy in RA. Aspirin's primary effect is on reducing inflammation and pain, not necessarily on altering WBC counts.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.