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 pulmonary function studies are an important part of the preoperative assessment and postoperative follow-up for lung cancer patients, they are not typically something a patient would be immediately prepared for post-lobectomy. These studies are usually scheduled for a later date to assess the impact of the surgery on lung function.
Choice B reason:
A sternal incision is not commonly associated with a lobectomy, which involves an incision in the chest wall, not the sternum. Sternal incisions are more often related to procedures that require access to the heart or the central chest area, such as open-heart surgery.
Choice C reason:
Moderate pain is expected after any major surgical procedure, including a lobectomy. However, pain management is a standard part of postoperative care, and patients are typically informed about pain control measures rather than being prepared to expect pain as a postoperative event.
Choice D reason:
The placement of a chest tube is a standard part of care following a lobectomy. The chest tube allows for drainage of fluid and air from the pleural space, ensuring proper lung expansion and preventing complications such as pneumothorax. Patients should be educated about the chest tube's purpose, care, and the sensations they may experience while the tube is in place.
Correct Answer is B
Explanation
Choice A reason:
The statement "This procedure is routinely performed during a Pap test" is incorrect. A colposcopy is not routinely performed during a Pap test; it is a separate procedure that is often recommended if a Pap test shows abnormal results. The colposcopy allows for a closer examination of the cervix, vagina, and vulva to detect any signs of disease.
Choice B reason:
The statement "During the procedure, a biopsy may be performed" is correct. If the healthcare provider sees an area of concern during the colposcopy, they may take a small sample of tissue (biopsy) from the cervix or from inside the opening of the cervix.
Choice C reason:
The statement "Do not eat or drink after midnight tonight" is not necessary for a colposcopy. Unlike some surgical procedures that require general anesthesia, a colposcopy is usually done with local anesthesia, and fasting is not required.
Choice D reason:
The statement "You will have general anesthesia during this procedure" is incorrect. General anesthesia is not typically used for a colposcopy. The procedure may cause some discomfort, but it is usually performed using local anesthesia or no anesthesia at all.
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