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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Moderate amount of foul-smelling lochia. This is the most indicative finding of a postpartum infection, as it suggests that the client has endometritis, which is an inflammation of the uterine lining. Endometritis is a common cause of maternal morbidity and mortality, and requires prompt antibiotic treatment.
Choice B: Blood pressure of 122/74 mm Hg. This is a normal blood pressure for a postpartum client, and does not indicate an infection. The reference range for blood pressure is 90/60 to 140/90 mm Hg.
Choice C: Oral temperature of 100.2°F (37.9°C.. This is a slightly elevated temperature for a postpartum client, but it does not necessarily indicate an infection. The reference range for oral temperature is 97.6 to 99.6°F (36.4 to 37.6°C.. A mild fever may occur in the first 24 hours after delivery due to dehydration or hormonal changes.
Choice D: White blood cell count of 19,000/mm³ (19 x 10⁹/L). This is a high white blood cell count for a postpartum client, but it does not indicate an infection. The reference range for white blood cell count is 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L). A leukocytosis may occur in the first few days after delivery due to stress or tissue injury.
Correct Answer is A
Explanation
Choice B reason: Reviewing the hemoglobin to determine hemorrhage is an important action, but not the first one. The nurse should first identify and correct the cause of bleeding, such as bladder distension or uterine atony, before checking for blood loss and anemia.
Choice C reason: Massaging the uterus to decrease atony is not indicated in this case, because the uterus is already firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D reason: Increasing intravenous infusion is not the first action, because it may worsen bleeding by increasing blood pressure and diluting clotting factors. The nurse should first assess and manage bleeding before administering fluids or blood products as prescribed.
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