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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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason:
Placing the leg under a heat lamp every 3 hours is not recommended for the treatment of cellulitis. Heat lamps can cause burns and excessive drying of the skin, which may worsen the condition.

Choice B reason:
Wrapping a warm, wet towel around the affected area is a safe and effective way to apply heat therapy for cellulitis. It can help improve blood flow and relieve discomfort without the risk of burns associated with dry heat sources.

Choice C reason:
Using a heating pad directly on the skin, especially when lying down, can increase the risk of burns and is not recommended for treating cellulitis. Heating pads can provide uneven heat and may exacerbate swelling and inflammation.

Choice D reason:
Soaking the leg in water is not typically advised for cellulitis, especially if there are open wounds or breaks in the skin. Immersion in water can introduce new bacteria to the affected area and potentially worsen the infection.

A. Hypertension B. Swollen calf C. Tachypnea D. Bradycardia

Correct Answer is C

Explanation

Choice A reason:
Hypertension is not typically an early manifestation of fat embolism syndrome (FES). FES is more commonly associated with hypoxemia, which can lead to hypotension rather than hypertension².

Choice B reason:
While a swollen calf may indicate deep vein thrombosis, it is not an early sign of FES. FES primarily affects the lungs and neurological systems early on, rather than causing localized swelling such as in a calf².

Choice C reason:
Tachypnea, or rapid breathing, is indeed an early sign of FES. This symptom usually develops before others and is due to the fat globules causing respiratory distress by blocking the pulmonary microcirculation²³⁴.

Choice D reason:
Bradycardia, or a slower than normal heart rate, is not an early sign of FES. Instead, patients may experience tachycardia as a response to hypoxemia and respiratory distress².

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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)

Nursing Test Bank

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