The nurse assesses a client with sepsis.
Which evaluations should the nurse include in a focused assessment? Select all that apply.

Breath sounds.

Urine output.

Capillary blood glucose.

Skin temperature.

Date of last bowel movement.

Answer and Explanation

Correct Answer : A,B,D

Sepsis requires a focused assessment of systemic perfusion and the inflammatory response. Knowledge of the Sequential Organ Failure Assessment criteria is necessary. The nurse must prioritize assessments that reflect respiratory function, renal perfusion, and peripheral microvascular status to detect early deterioration.

Choice A rationale

Sepsis often leads to increased capillary permeability and acute lung injury. Assessing breath sounds allows the nurse to detect adventitious sounds like crackles, which may indicate the development of pulmonary edema or progressing respiratory distress or infection.

Choice B rationale

Urine output is a primary indicator of organ perfusion. In sepsis, decreased output less than 0.5 mL per kg per hr suggests inadequate renal blood flow or acute kidney injury resulting from systemic hypotension and inflammatory damage.

Choice C rationale

While glucose levels can fluctuate during the stress response of sepsis, it is not a primary component of a focused sepsis assessment compared to hemodynamic markers. Hyperglycemia is common but does not specifically define the septic state.

Choice D rationale

Skin temperature and capillary refill provide information about peripheral perfusion. In early sepsis, skin may be warm due to vasodilation, while late sepsis often presents with cool, clammy skin as the body shunts blood to organs.

Choice E rationale

The date of the last bowel movement is a part of a general gastrointestinal assessment but is not a priority in a focused sepsis evaluation. It does not provide immediate data regarding systemic inflammatory response or perfusion..

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Correct Answer is ["B","D","E","F"]

Explanation

Managing SIADH requires understanding water metabolism and the effects of excessive antidiuretic hormone. Knowledge of fluid volume excess, dilutional hyponatremia, and neurological risks is applied to select interventions that correct electrolyte imbalances and prevent life-threatening cerebral edema.

Choice A rationale

Blood glucose monitoring is not a standard intervention for SIADH. While brain tumors can affect various hormones, SIADH specifically impacts water retention and sodium levels rather than the insulin-glucagon axis or glucose metabolism directly.

Choice B rationale

Tolvaptan is a vasopressin receptor antagonist that promotes the excretion of free water without losing electrolytes. It is specifically used in SIADH to treat euvolemic hyponatremia by blocking the effects of excessive antidiuretic hormone.

Choice C rationale

SIADH causes fluid retention and volume expansion, leading to moist mucous membranes and fluid overload. Assessing for dry membranes is more appropriate for dehydration or diabetes insipidus, which is the opposite of SIADH.

Choice D rationale

SIADH leads to dilutional hyponatremia (normal sodium 135 to 145 mEq/L). Frequent monitoring is essential because low sodium levels can lead to mental status changes, muscle twitching, and life-threatening cerebral edema if not managed.

Choice E rationale

Fluid restriction is the primary treatment for SIADH. By limiting intake, the body can slowly correct the dilutional hyponatremia. This prevents further expansion of the intravascular volume and reduces the risk of worsening hyponatremia.

Choice F rationale

Severe hyponatremia significantly increases the risk of seizures due to brain cell swelling. Implementing seizure precautions (padded side rails, suction equipment) is a critical safety measure for any patient with rapidly falling or low sodium.

A. Dilantin should be mixed in dextrose in water before administration. B. Dilantin should be administered through an IV catheter in the client's hand. C. Rapid Dilantin administration can cause cardiac dysrhythmias. D. Therapeutic drug levels should be maintained between 20 to 30 mg/mL.

Correct Answer is C

Explanation

Administering phenytoin requires applying knowledge of intravenous drug compatibility and cardiovascular safety profiles. The nurse must prioritize monitoring for life-threatening complications associated with rapid infusion, specifically focusing on the drug's narrow therapeutic index and its significant irritant properties.

Choice A rationale

Phenytoin is highly unstable and will precipitate if mixed with dextrose solutions. It must only be diluted with 0.9 percent sodium chloride. Incorrect dilution can lead to crystalline emboli and loss of drug efficacy during administration.

Choice B rationale

Intravenous phenytoin is a known vesicant that can cause purple glove syndrome if administered into small peripheral veins like those in the hand. Use of a large-bore catheter in a large vein or central line is preferred.

Choice C rationale

Rapid infusion of phenytoin can lead to severe cardiovascular collapse, including hypotension and fatal dysrhythmias. The infusion rate should not exceed 50 mg per minute to allow the heart to tolerate the drug's membrane-stabilizing effects safely.

Choice D rationale

The standard therapeutic range for phenytoin is 10 to 20 mcg per mL, not 20 to 30 mg per mL. Levels exceeding 20 mcg per mL often result in toxicity, characterized by nystagmus, ataxia, and decreased mental status.

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The nurse assesses a client with sepsis. Which evaluations should the nurse include in a focused assessment? Select all that apply.

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The nurse plans care for a client with a brain tumor who developed a syndrome of inappropriate antidiuretic hormone. Which interventions should the nurse include in the plan? Select all that apply.

Correct Answer is ["B","D","E","F"]

Explanation

The nurse prepares to administer a 1,000 mg loading dose of phenytoin IV to a client with a subarachnoid hemorrhage. Which consideration is most important when administering this dose?

Correct Answer is C

Explanation

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The nurse assesses a client with sepsis.
Which evaluations should the nurse include in a focused assessment? Select all that apply.