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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
To answer this question, we need to use the formula:
IV flow rate (gtt/min) = (Volume to be infused in mL x Drop factor in gtt/mL) / Time of infusion in minutes
Plugging in the given values, we get:
IV flow rate (gtt/min) = (100 mL x 60 gtt/mL) / 60 min Simplifying, we get:
IV flow rate (gtt/min) = 100 gtt/min
Therefore, the nurse should set the IV flow rate to deliver 100 gtt/min.
Correct Answer is D
Explanation
A. While discomfort can occur, it is not an expected or acceptable part of end-of-life care. Effective pain management is a key priority, and discomfort should be addressed promptly to ensure the client’s comfort and dignity.
B. While true, this statement does not directly address the expectation of discomfort at the end of life.
C. While pain can be present in older adults, the statement does not specifically address the end-of-life context.
D.Fear of addiction is a common concern among clients and families, even at the end of life. Nurses should educate clients and families about the importance of managing pain effectively and emphasize that addiction is not a concern when opioids are used appropriately for end-of-life care. This helps alleviate anxiety and encourages adherence to prescribed pain management regimens.
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