Patient Data

Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Temperature 98.8° F (37.1° C)

Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic

Serum blood glucose 185 mg/dL (10.2 mmol/L)

White blood cell count 11.2 x 103/µL (11.2 x 109/L)

Capillary refill greater than 3 seconds bilateral lower extremities

Bilateral lower extremities skin warm, dry, and pink

Answer and Explanation

Correct Answer : A,D,F

Rationale:
A. Temperature 98.8° F (37.1° C): A normal body temperature indicates resolution of the infection and a positive response to antibiotic therapy for cellulitis. Fever reduction is a key indicator of therapeutic effectiveness.

B. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: While pain is low, the description of neuropathic pain unrelated to cellulitis does not reflect improvement in the infection itself, so it is not a primary indicator of therapeutic response.

C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although improved from the initial hyperglycemia, this level is still above the normal range. It does not directly indicate resolution of cellulitis or therapeutic effectiveness of antibiotic therapy.

D. White blood cell count 11.2 x 103/µL (11.2 x 10⁹/L): The decrease toward normal limits from an elevated WBC demonstrates a positive hematologic response to treatment and reduced systemic inflammation caused by the infection.

E. Capillary refill greater than 3 seconds bilateral lower extremities: Prolonged capillary refill indicates peripheral perfusion deficits. Persistent abnormal refill is not a sign of therapeutic response and may reflect ongoing vascular compromise.

F. Bilateral lower extremities skin warm, dry, and pink: Improvement in skin color, warmth, and absence of edema or erythema reflects resolution of cellulitis and effective local tissue recovery, consistent with therapeutic response.

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Correct Answer is ["B","F","G","H"]

Explanation

A. Notify the social worker the client is awake: The social worker is already attempting to contact family. Awakening does not require immediate notification; the priority is client care and stabilization.

B. Explain all procedures: As the client becomes more alert, clear explanations reduce anxiety, promote cooperation, and support orientation, especially in the ICU environment.

C. Increase the propofol infusion: Increasing sedation without clinical indication may mask neurological changes and hinder assessment. Sedative adjustments should be based on prescribed parameters and provider orders.

D. Consider extubating the client: Extubation is only considered when specific respiratory and hemodynamic criteria are met. Waking up does not automatically mean the client is ready to be extubated.

E. Have the client sign consent forms for procedures already performed: Consent must be obtained prior to procedures. Once completed, retroactive consent is not valid or ethical.

F. Assess the client’s pain: Pain assessment is essential in postoperative and trauma patients, particularly once the client is able to communicate.

G. Determine the client’s decision-making ability: As the client becomes more awake, assessing cognitive status and ability to participate in care decisions is appropriate and supports autonomy.

H. Decrease the noise and light stimuli in the room as much as possible: Minimizing environmental stimuli helps reduce delirium risk, improves comfort, and promotes healing in critically ill patients.

A. Ensure that the restraints are snug against the client's wrists. B. Move the ties so the restraints are secured to the side rails. C. Ensure that the knot can be quickly released. D. Tie the knot with a double turn or square knot.

Correct Answer is C

Explanation

A. Ensure that the restraints are snug against the client's wrists: Restraints should be snug enough to prevent injury but not so tight as to impair circulation. However, this does not address the safety concern related to the type of knot used.

B. Move the ties so the restraints are secured to the side rails: Restraints should never be tied to the side rails because this can cause injury if the rail moves or the client attempts to climb over it.

C. Ensure that the knot can be quickly released: Using a quick-release knot, such as a half bow or slip knot, is essential to ensure the nurse can rapidly remove the restraints in an emergency, such as sudden respiratory distress or circulatory compromise.

D. Tie the knot with a double turn or square knot: Square knots are secure but not quick to release. In contrast, safety guidelines recommend quick-release knots for client restraints to allow for prompt intervention.

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Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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Patient Data

Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.