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 C
Explanation
Choice A reason: Hypertension
Hypertension, or high blood pressure, is not typically an expected finding in hypovolemic shock. In fact, one would expect the opposite, hypotension, due to the decreased circulating blood volume. Hypertension might be present in the initial stages due to compensatory mechanisms, but as the condition progresses, blood pressure usually drops.
Choice B reason: Bradypnea
Bradypnea, or abnormally slow breathing, is not a common finding in hypovolemic shock. Instead, tachypnea, or rapid breathing, may be observed as the body attempts to compensate for reduced oxygen delivery to tissues.
Choice C reason: Oliguria
Oliguria, or low urine output, is an expected finding in hypovolemic shock. As the blood volume decreases, the kidneys receive less blood flow, leading to reduced urine production. This is a protective mechanism to conserve body fluids, but it also indicates the severity of fluid loss and the need for urgent intervention.
Choice D reason: Flushing of the skin
Flushing of the skin is not an expected finding in hypovolemic shock. Instead, the skin may appear pale, cool, and clammy due to vasoconstriction and reduced blood flow to the periphery as the body prioritizes blood flow to vital organs.
Correct Answer is A
Explanation
Choice A reason: Effective hand hygiene is the most important measure to prevent the transmission of hepatitis A, as the virus can be spread through close personal contact and by eating food or drinking water handled by someone who is infected¹. Handwashing with soap and water after using the bathroom, changing diapers, and before preparing or eating food is crucial.
Choice B reason: While avoiding raw foods can help prevent the transmission of various foodborne illnesses, hepatitis A is not commonly associated with raw foods unless they are contaminated during handling after cooking. However, it is still a good practice to avoid raw or undercooked foods in areas where hepatitis A is common.
Choice C reason:
Hepatitis A virus is primarily transmitted via the fecal-oral route, not through sexual contact. However, barrier protection can reduce the risk of transmission for many other infections, including other types of viral hepatitis that are sexually transmitted.
Choice D reason:
Eating at fast food restaurants is not inherently risky for hepatitis A transmission unless the food or water is contaminated. It is more important to ensure that all food is properly handled and cooked, regardless of the dining establishment.
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