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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.
Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.
Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.
Correct Answer is D
Explanation
Choice A reason: Quiet, calm surroundings are not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, they may be beneficial for promoting rest and comfort for the client.
Choice B reason: Stimulating sounds and activity are not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, they may be helpful for enhancing mood and cognition for the client.
Choice C reason: Cool, moist air is not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, it may be preferable for preventing dehydration and overheating for the client.
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