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 A

Explanation

This scenario involves end of life care and ethical communication regarding physiological changes during the dying process. Knowledge of palliative care principles and the natural slowing of metabolic processes is required to address the family's concerns and provide reassurance.

Choice A rationale

Explaining that anorexia is a natural part of the dying process validates the physiological reality that the body no longer requires fuel. Discussing aspiration risk helps the wife understand that forced feeding could cause harm or discomfort.

Choice B rationale

Nutritional consults and preferred foods are ineffective when a client is actively dying. The focus shifts from nutritional maintenance to comfort. Interventions aimed at increasing caloric intake do not prolong life or improve quality at this terminal stage.

Choice C rationale

While keeping foods available seems supportive, it can create pressure on the client and frustration for the family. In the final stages of life, many clients lack the physical strength or reflex capability to safely consume bedside snacks.

Choice D rationale

Encouraging the wife to feed the client as much as possible increases the risk of choking and aspiration. It places an undue burden on the caregiver and may cause the client physical distress, as their digestive system slows.

A. Different blood pressures in the upper limbs. B. Differences in upper and lower lung sounds. C. Different apical and radial pulses. D. Differences between oral and axillary temperatures.

Correct Answer is C

Explanation

Identifying cardiac arrhythmias requires understanding the relationship between electrical conduction and mechanical output. Knowledge of pulse deficits is necessary to recognize when rapid, irregular atrial contractions fail to produce adequate ventricular filling and a palpable peripheral pulse.

Choice A rationale

Blood pressure discrepancies between the upper limbs usually indicate vascular issues like aortic dissection or peripheral arterial disease. Atrial fibrillation affects the rhythm and volume of the pulse rather than creating localized pressure differences between the arms.

Choice B rationale

Variations in lung sounds typically suggest localized pulmonary pathology such as pneumonia or pleural effusion. While atrial fibrillation can lead to heart failure and pulmonary edema, it does not specifically cause differences between upper and lower sounds.

Choice C rationale

A pulse deficit occurs when the apical heart rate is higher than the radial rate. In atrial fibrillation, some ventricular contractions are too weak to perfuse to the periphery, making this a classic assessment finding.

Choice D rationale

Discrepancies between oral and axillary temperatures relate to thermoregulation and measurement accuracy rather than cardiac rhythm. Temperature monitoring is used to screen for infection or inflammation but does not provide diagnostic information regarding atrial arrhythmias..

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