A nurse receives a report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?

Notify the primary health care provider and request antibiotics.

Inform the client that this signifies inflammation.

Document findings and continue monitoring.

Place the client in protective isolation.

Answer and Explanation

The Correct Answer is A

Rationale for Choice A:
A shift to the left in the white blood cell (WBC) count indicates an increased presence of immature neutrophils, known as bands. This is a hallmark sign of infection, as the body is rapidly producing and releasing these cells to fight off invading pathogens.
Prompt notification of the primary health care provider is crucial to initiate timely antibiotic therapy, if indicated. Early intervention with appropriate antibiotics can effectively combat the infection, prevent its progression, and potentially avert serious complications.
Delaying antibiotic treatment can allow the infection to worsen, potentially leading to sepsis, septic shock, or other life- threatening conditions.
Rationale for Choice B:
While informing the client about the significance of a shift to the left is important for education and understanding, it does not address the immediate need for medical intervention.
The priority action is to involve the primary health care provider for prompt assessment and potential initiation of antibiotic therapy.
Rationale for Choice C:
Documenting findings and continuing to monitor the client's condition is essential for ongoing assessment and evaluation, but it does not constitute a proactive intervention to address the underlying infection.
Documentation alone does not initiate treatment, and monitoring without intervention risks allowing the infection to progress.
Rationale for Choice D:
Protective isolation is not routinely indicated for clients with a shift to the left in their WBC count unless there is a specific concern for transmission of a highly contagious infection.
The decision to implement protective isolation measures would be based on the client's overall clinical presentation and potential infectious risks, as determined by the primary health care provider.

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Correct Answer is B

Explanation

Choice A rationale:
A serum sodium level of 134 mEq/L (134 mmol/L) is mildly low, but this level of hyponatremia is not typically associated with significant cognitive impairment.
Symptoms of hyponatremia, such as confusion, lethargy, and seizures, usually occur when sodium levels are 125 mEq/L or lower.
However, it's important to monitor this patient for any changes in cognitive status as hyponatremia can worsen and lead to more severe symptoms.
Choice C rationale:
A patient who underwent an open cholecystectomy two days ago may experience some cognitive impairment due to the effects of anesthesia and pain medications.
However, this type of impairment is usually temporary and resolves within a few days.
It's important to assess for cognitive impairment in this patient, but it is not the most urgent priority.
Choice D rationale:
A 32-year-old patient with a 20-pack-year history of smoking is at risk for cognitive impairment due to the long-term effects of smoking on the brain.
However, this risk is typically not as immediate as the risk of cognitive impairment following a stroke.
It's important to educate this patient about the risks of smoking and encourage smoking cessation, but it is not the most urgent priority in terms of cognitive assessment.
Choice B rationale:
An 88-year-old patient who had a hemorrhagic stroke three days ago is at the highest risk for cognitive impairment among the given options.
Hemorrhagic stroke involves bleeding in the brain, which can damage brain tissue and lead to cognitive deficits.
The risk of cognitive impairment is particularly high in older adults, as they may have less cognitive reserve to compensate for the damage caused by the stroke.
Early assessment and intervention for cognitive impairment are crucial for optimizing recovery and quality of life in stroke patients.
Prompt evaluation for cognitive impairment is essential to identify any deficits and initiate appropriate interventions to support the patient's cognitive function and recovery.

A. The PICC was inserted 4 weeks ago. B. The initial site dressing is 3 days old. C. A securement device is missing. D. Swelling is observed in the upper extremity.

Correct Answer is D

Explanation

Choice A rationale:
While PICCs are typically intended for shorter-term use (up to 12 weeks), the fact that a PICC has been in place for 4 weeks is not, in itself, an immediate cause for concern. Regular assessment of the catheter and site is crucial, but the duration of placement alone does not warrant immediate attention.
Choice B rationale:
While it's generally recommended to change PICC dressings every 7 days, a dressing that is 3 days old is not an immediate emergency. The nurse should prioritize changing the dressing as soon as possible, but it does not require the same level of urgency as other potential complications.
Choice C rationale:
A missing securement device is a concern because it can increase the risk of catheter dislodgement or migration. However, it does not necessarily indicate an immediate threat to the patient's well-being. The nurse should promptly address the missing securement device, but it would not be the most pressing issue compared to swelling in the extremity.
Choice D rationale:
Swelling in the upper extremity where the PICC is located is a significant finding that demands immediate attention. It can be a sign of several serious complications, including:
Thrombosis: A blood clot within the vein, which can obstruct blood flow and lead to pain, swelling, and potentially more severe consequences like deep vein thrombosis (DVT) or pulmonary embolism (PE).
Infection: Inflammation and infection at the insertion site or within the bloodstream, which can cause swelling, redness, warmth, and pain. If left untreated, infection can progress to sepsis, a life-threatening condition.
Phlebitis: Inflammation of the vein, which can cause pain, redness, and swelling along the vein.
Infiltration: Leakage of fluids or medications into the surrounding tissue, leading to swelling and discomfort.
Prompt action is crucial in these cases to prevent further complications and ensure patient safety. The nurse should immediately notify the appropriate healthcare provider, initiate necessary interventions, and closely monitor the patient's condition.

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A nurse receives a report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A nurse is evaluating patients who have been prescribed intravenous therapy. Which observation for a patient with a Peripherally Inserted Central Catheter (PICC) demands immediate attention?

Correct Answer is D

Explanation

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