A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

Vomiting Hypoglycemia

Hypertension

Altered mental status

Elevated WBC’s count

Answer and Explanation

The Correct Answer is C

A.   Vomiting is not a specific manifestation of sepsis.
B.   Hypertension is not a typical finding in sepsis; hypotension is more common.
C.   Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D.   While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.

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Correct Answer is B

Explanation

A. Non-palpable spleen is not a typical manifestation of malnutrition but may be associated with other health conditions.
B. Rough, dry skin is a common manifestation of malnutrition, reflecting deficiencies in essential nutrients affecting skin health.
C. The presence of surface papillae on the tongue is not specifically associated with malnutrition.
D. Slightly moist skin is less likely in malnutrition; dry skin is more characteristic.

A. Use clean technique when changing the catheter dressing. B. Change the catheter dressing every 2 days. C. Clean the access port on the CVAD line with povidone-iodine prior to use D. Perform hand hygiene for 10 sec prior to changing the catheter dressing. E. Use friction when cleaning the access port.

Correct Answer is ["A","D"]

Explanation

A. Using clean technique helps prevent contamination during catheter dressing changes.
B. Changing the catheter dressing every 2 days may not be necessary, and frequency should be based on the facility's policy and the client's condition.
C. Povidone-iodine is not the recommended antiseptic for cleaning the access port.
Alcohol or chlorhexidine is typically recommended.
D. Proper hand hygiene is crucial to prevent introducing pathogens during catheter care.
E. Using friction when cleaning the access port is not a recommended practice and may cause damage. Cleaning should be done gently to avoid compromising the integrity of the site.

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A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client. Exhibits The nurse is assisting with catheter care for the client to prevent a central line-associated bloodstream infection (CLABSI bundle). Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","D"]

Explanation

A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

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