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 ["25"]

Explanation

To answer this question, you need to use the formula:

gtt/min = (Volume x Drop factor) / Time

Plug in the given values:

gtt/min = (100 mL x 15 gtt/mL) / 60 min

Simplify and solve:

gtt/min = 1500 gtt / 60 min gtt/min = 25 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 25 gtt/min.

A. Shake the ampule to move the solution below the neck. B. Snap the top of the ampule towards hands. C. Wear sterile gloves when withdrawing the medication from the ampule. D. Use a filter needle to draw up the medication.

Correct Answer is D

Explanation

A. Shaking the ampule is not necessary and can create air bubbles in the solution.
B. Snapping the top of the ampule towards the hands is not recommended, as it can cause injury. The top should be snapped away from the nurse.
C. Sterile gloves may be worn for other aspects of the procedure, but it is not necessary to wear them specifically when withdrawing medication from the ampule.
D. Using a filter needle helps prevent glass particles from entering the syringe when withdrawing medication from an ampule.

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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 preparing to administer dextrose 5% in water (DSW) 100 mL to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

Correct Answer is ["25"]

Explanation

A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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