An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postburn infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8°F (39.3°C., heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?

Provide bedside equipment for transmission and protective precautions.

Evaluate daily serum electrolytes and hydration status.

Culture sputum, urine, burn wound, and all intravenous access sites.

Implement central line-associated bloodstream infection (CLABSI) protocols.

Answer and Explanation

The Correct Answer is C

Choice A: Providing bedside equipment for transmission and protective precautions is not the first action that the nurse should implement, as this is a standard precaution that should be already in place for all clients in the critical care unit. This is a distractor choice.

Choice B: Evaluating daily serum electrolytes and hydration status is not the first action that the nurse should implement, as this is a routine assessment that can be done later after addressing the immediate problem of infection. This is another distractor choice.

Choice C: Culturing sputum, urine, burn wound, and all intravenous access sites is the first action that the nurse should implement, as this can help identify the source and type of infection, which can guide the appropriate antibiotic therapy and prevent further complications. Therefore, this is the correct choice.

Choice D: Implementing central line-associated bloodstream infection (CLABSI) protocols is not the first action that the nurse should implement, as this is a preventive measure that may not be applicable for this client who already has SIRS. This is another distractor choice.

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Naxlex Comprehensive Predictor Exams

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

Explanation

Choice A reason: Consuming foods with saturated fats can increase the level of low-density lipoprotein (LDL) cholesterol in the blood, which can contribute to plaque formation and narrowing of the coronary arteries.

Choice B reason: Walking 30 minutes per day can help lower blood pressure, improve blood circulation, and reduce the risk of heart attack and stroke.

Choice C reason: Using a salt substitute can help lower sodium intake, which can reduce fluid retention and lower blood pressure.

Choice D reason: Keeping a food diary can help the client monitor their calorie intake, portion size, and nutritional balance.

Choice E reason: Eating more canned vegetables can increase sodium intake, which can worsen fluid retention and blood pressure. Fresh or frozen vegetables are preferable.

Choice F reason: Including oatmeal for breakfast can provide soluble fiber, which can lower LDL cholesterol and prevent plaque formation in the coronary arteries.

A. Consume foods with saturated fats. B. Walk 30 minutes per day. C. Use a salt substitute. D. Keep a food diary. E. Eat more canned vegetables. F. Include oatmeal for breakfast.

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

Explanation

Choice A: Consuming foods with saturated fats is not a healthy lifestyle change for a client with coronary artery disease, as this can increase the level of cholesterol and triglycerides in the blood, which can lead to plaque formation and narrowing of the arteries. Therefore, this statement indicates that the client needs additional education.

Choice B: Walking 30 minutes per day is a beneficial lifestyle change for a client with coronary artery disease, as this can improve the blood circulation, lower the blood pressure, and reduce the risk of heart attack and stroke. Therefore, this statement does not indicate that the client needs additional education.

Choice C: Using a salt substitute is a helpful lifestyle change for a client with coronary artery disease, as this can reduce the sodium intake, which can lower the blood pressure and prevent fluid retention. Therefore, this statement does not indicate that the client needs additional education.

Choice D: Keeping a food diary is a useful lifestyle change for a client with coronary artery disease, as this can help the client monitor their calorie intake, portion size, and nutritional quality of their food. This can also help the client identify and avoid unhealthy food choices. Therefore, this statement does not indicate that the client needs additional education.

Choice E: Eating more canned vegetables is not a good lifestyle change for a client with coronary artery disease, as canned vegetables often contain high amounts of sodium, which can raise the blood pressure and worsen the condition. Therefore, this statement indicates that the client needs additional education.

Choice F: Including oatmeal for breakfast is an advantageous lifestyle change for a client with coronary artery disease, as oatmeal contains soluble fiber, which can lower the cholesterol level and prevent plaque formation in the arteries. Therefore, this statement does not indicate that the client needs additional education.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Text 1:The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

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

Explanation

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

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

Explanation

The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to ask in the assessment of this client?

Days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client had a pulmonary embolus. Which action should the nurse take first?

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding this client?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?