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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Correct Answer is D

Explanation

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

A. Ask for a consultation with a psychologist. B. Arrange an appointment with a pain specialist. C. Contact a hospice nurse for an evaluation. D. Form an interdisciplinary team for evaluation.

Correct Answer is B

Explanation

Choice A: Ask for a consultation with a psychologist. This is not the best intervention, as it does not address the physical aspect of pain management. A psychologist may help the client cope with emotional distress and cognitive-behavioral strategies to reduce pain perception, but it may not be enough to relieve severe pain.

Choice B: Arrange an appointment with a pain specialist. This is the best intervention, as it addresses the physical aspect of pain management. A pain specialist may prescribe appropriate medications, perform interventional procedures, or recommend alternative therapies to relieve severe pain.

Choice C: Contact a hospice nurse for an evaluation. This is not the best intervention, as it does not address the eligibility criteria for hospice care. Hospice care is intended for clients who have a terminal illness with a life expectancy of six months or less, and who have decided to forego curative treatments. Fibromyalgia is not a terminal illness, and hospice care may not be appropriate for this client.

Choice D: Form an interdisciplinary team for evaluation. This is not the best intervention, as it does not address the urgency of pain management. An interdisciplinary team may consist of various healthcare professionals who can provide holistic care for the client, but it may take time to coordinate and implement their services.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Correct Answer is D

Explanation

A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?

Correct Answer is B

Explanation

The nurse is preparing a dose of 10 mg of teriparatide. The medication is labeled 760 mcg/2.4 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client?

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm and three fingerbreadths above the umbilicus. What action should the nurse implement first?

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?