Patient Data
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
A. St. John's wort: This herbal supplement is not used to manage opioid side effects and may interact with other medications, including opioids, making it inappropriate for this purpose.
B. Sildenafil: Sildenafil is used to treat erectile dysfunction and has no role in managing morphine side effects. It is unrelated to pain management or opioid-related adverse effects.
C. Ondansetron: Ondansetron is an antiemetic commonly prescribed to prevent or treat nausea and vomiting, which are frequent side effects of morphine administration.
D. Naloxone: Naloxone is an opioid antagonist used to reverse severe opioid-induced respiratory depression. It is essential for emergency management of potentially life-threatening side effects of morphine.
E. Meperidine: Meperidine is an opioid analgesic and is not used to treat side effects of morphine. Using another opioid would not address morphine-induced complications and may increase risk of adverse effects.
F. Docusate sodium: Opioid-induced constipation is common with morphine. Docusate sodium is a stool softener used prophylactically to prevent or treat constipation associated with opioid therapy.
Correct Answer is A
Explanation
A. Last dose and type of rescue inhaler used by the child: Knowing the timing and type of rescue medication is critical in an acute asthma exacerbation to determine if additional doses or alternative therapies are needed immediately.
B. Frequency that the child uses a rescue inhaler during the week: While important for long-term asthma management, it is less critical during an acute, life-threatening episode where immediate intervention is required.
C. Type of allergen exposure or trigger for the current episode: Identifying triggers can help prevent future episodes but does not influence immediate treatment for the child’s current severe respiratory distress.
D. Type of inhaler the child typically uses on a regular basis: Knowing routine inhalers is relevant for chronic management but does not provide immediate guidance for emergency treatment of acute airway compromise.
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