A nurse is caring for an older adult client who is suspected of having septicemia.
Which of the following actions is the nurse's priority?
Obtain a WBC count with differential.
Obtain a blood specimen for culture and sensitivity testing.
Obtain a history to determine recent injuries.
Obtain a broad-spectrum antibiotic for rapid administration.
The Correct Answer is B
The priority action for a nurse caring for an older adult client who is suspected of having septicemia is to obtain a blood specimen for culture and sensitivity testing.
This test will help identify the specific microorganism causing the infection and determine the most effective antibiotic treatment.
Choice A is incorrect because while a WBC count with differential can provide information about the presence of an infection, it does not identify the specific microorganism causing the infection.
Choice C is incorrect because while obtaining a history to determine recent injuries can provide useful information, it is not the priority action.
Choice D is incorrect because while administering a broad-spectrum antibiotic may be necessary, it should not be done before obtaining a blood specimen for culture and sensitivity testing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
Correct Answer is C
Explanation
When administering packed RBCs, the tubing should be primed with 0.9% sodium chloride.
Transfusing each unit of blood over 5 hours (choice A) is not recommended as it may increase the risk of bacterial growth.
Packed RBCs should be transfused over 2 to 3 hours.
Changing the IV tubing after each unit of blood is transfused (choice B) is not necessary.
Administering the blood through a 22-gauge intravenous catheter (choice D) may not be appropriate as a larger gauge catheter is typically used for blood transfusions.
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