The nurse continues to assist in the care of the client.
Complete the following sentence by using the lists of options.
The nurse should first ensure administration of the client's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
In clinical practice, when a provider issues new prescriptions, the nurse must prioritize administration based on the client’s current physiological stability and the severity of their symptoms, in this case, an older adult ICU client with suspected postoperative infection and worsening sepsis. The client presents with fever, hypotension, elevated and rising WBC count, and an infected surgical wound with purulent drainage. These findings indicate an active bacterial infection requiring urgent antimicrobial therapy. In sepsis management, treating the underlying infection takes priority over symptom control measures such as fever reduction or anxiety management.
Rationale for correct choices:
• Antibiotic: The priority intervention is administration of the prescribed antibiotic because the client shows clear signs of systemic infection progressing toward sepsis. The infected surgical wound with purulent drainage, fever, hypotension, and increasing WBC count confirm an active bacterial process. Cefazolin targets the underlying cause, which is essential to stop infection progression and prevent further organ dysfunction. Without timely antibiotic therapy, the client’s condition will continue to deteriorate despite supportive care.
• WBC count: The rising WBC count is a key indicator of worsening infection and systemic inflammatory response. It reflects the body’s immune response to bacterial invasion and helps confirm the severity of sepsis. The increase from 14,000/mm³ to 15,000/mm³ indicates progression despite initial concern. This laboratory trend supports prioritizing antibiotic therapy over symptom-focused interventions.
Rationale for incorrect choices:
• Antipyretic: Antipyretics such as acetaminophen help reduce fever but do not treat the underlying infection causing the client’s instability. Although the client has an elevated temperature, fever is a symptom rather than the primary problem. Administering antipyretics without treating the infection could mask worsening sepsis.
• Anti-anxiety medication: Alprazolam may help manage agitation or anxiety, but it does not address the life-threatening infectious process. The client’s restlessness is likely secondary to delirium caused by infection and fever. Sedating the client without treating the cause may worsen confusion and respiratory status.
• Restlessness: This is a clinical manifestation of delirium and infection-related distress, but it is not the primary indicator guiding urgent treatment decisions. It is a symptom rather than an objective marker of disease progression. While it requires supportive care, it does not direct priority pharmacologic therapy. Laboratory evidence of infection (WBC count) is more critical for guiding immediate treatment.
• Temperature: This reflects the presence of fever, which is a symptom of infection but not the most reliable indicator for prioritizing treatment in this scenario. Although the client is febrile (39.1°C), fever alone does not quantify the severity or progression of infection as accurately as laboratory findings such as WBC trends. In sepsis management, rising WBC count and hemodynamic instability provide stronger evidence of systemic infection requiring immediate antibiotic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Warfarin is an anticoagulant that works by inhibiting vitamin K–dependent clotting factors (II, VII, IX, and X). When toxicity occurs, patients are at high risk for bleeding due to excessive anticoagulation. Management focuses on reversing the anticoagulant effect to restore normal clotting function. The specific antidote depends on the medication involved, and in warfarin toxicity, vitamin K is the primary reversal agent.
Rationale:
A. Acetylcysteine is the antidote for acetaminophen (paracetamol) toxicity, not warfarin overdose. It works by replenishing glutathione stores to prevent liver damage from toxic metabolites. It has no role in reversing anticoagulation or restoring clotting factor activity.
B. Calcium gluconate is used to treat hypocalcemia and stabilize cardiac membranes in hyperkalemia. It does not reverse anticoagulation or affect vitamin K–dependent clotting pathways. Therefore, it is not indicated for warfarin toxicity management.
C. Protamine sulfate is the antidote for heparin toxicity, not warfarin. It works by binding to heparin and neutralizing its anticoagulant effect. Since warfarin acts through a different mechanism (vitamin K inhibition), protamine is ineffective in this situation.
D. Vitamin K is the specific antidote for warfarin toxicity because it promotes the synthesis of vitamin K–dependent clotting factors in the liver. Administering vitamin K helps reverse excessive anticoagulation and reduces the risk of bleeding. In severe cases, additional therapies such as fresh frozen plasma may be used, but vitamin K remains the primary treatment.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
This patient presents with an early pregnancy complication, presenting with abdominal pain, delayed menses, positive pregnancy test, and vaginal spotting. Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, most commonly in the fallopian tube. It is a life-threatening condition if not identified early due to risk of tubal rupture and hemorrhage. Key clinical clues include unilateral lower abdominal pain, abnormal vaginal bleeding, and a positive hCG with pain localized to one side.
Rationale for correct choices:
• The client’s presentation is highly suggestive of ectopic pregnancy due to delayed menses, positive hCG, abdominal pain, and vaginal spotting. A significant risk factor is the history of pelvic inflammatory disease, which can cause tubal scarring and abnormal implantation. Ectopic pregnancies commonly present with unilateral lower abdominal pain and irregular bleeding in early gestation. Without timely intervention, rupture can lead to severe internal bleeding and shock.
• Right lower quadrant tenderness is a classic finding in ectopic pregnancy, particularly when implantation occurs in the right fallopian tube. This localized pain reflects tubal distention or early rupture at the implantation site. It is more specific than generalized abdominal discomfort and aligns with the client’s reported symptoms and assessment findings. Combined with positive pregnancy test and spotting, it strongly supports ectopic pregnancy.
Rationale for incorrect choices:
• Abruptio placentae involves premature separation of the placenta from the uterine wall and typically occurs in the second or third trimester, not at 6 weeks gestation. It presents with painful vaginal bleeding, uterine rigidity, and fetal distress. This client is in early pregnancy with no evidence of advanced gestation or uterine hypertonicity. Therefore, this condition is not consistent with the presentation.
• Pyelonephritis is a kidney infection characterized by fever, flank pain, costovertebral angle tenderness, and urinary symptoms such as dysuria or urgency. This client does not report fever, urinary symptoms, or flank pain. The abdominal pain is localized to the right lower quadrant and associated with vaginal spotting and pregnancy. These findings are not consistent with a urinary tract infection involving the kidneys.
• Placenta previa occurs in later pregnancy when the placenta partially or completely covers the cervical os, leading to painless, bright red vaginal bleeding. This client is only 6 weeks pregnant, making placenta previa physiologically impossible at this stage. Additionally, placenta previa does not present with abdominal pain or localized tenderness. Therefore, it is is not applicable.
• An acute asthma attack presents with respiratory symptoms such as wheezing, shortness of breath, and decreased oxygenation. While the client has mild inspiratory wheezes, there are no signs of respiratory distress or exacerbation. The primary concerns in this case are gynecologic, not respiratory. Therefore, asthma is not the primary condition explaining the overall clinical picture.
• Respiratory rate is not directly associated with ectopic pregnancy diagnosis in this client. While it is part of general vital sign assessment, the client’s respiratory status is stable and not the primary indicator of the condition. Mild wheezing related to asthma does not explain the abdominal and reproductive findings.
• A history of regular menstrual cycles is a baseline reproductive pattern and does not indicate a current complication. Although it supports the concept of a missed period, it is not a clinical finding that confirms ectopic pregnancy. It is nonspecific and does not explain the current pain or bleeding.
• Hyperactive bowel sounds are related to gastrointestinal activity and may be influenced by anxiety or nonspecific abdominal irritation. They are not characteristic of ectopic pregnancy and do not localize the pathology to the reproductive system. This finding does not help differentiate ectopic pregnancy from other conditions.
• Temperature is typically normal in ectopic pregnancy unless there is rupture and secondary infection or inflammation. The client does not demonstrate fever or systemic infection signs. Therefore, temperature is not a useful indicator for identifying ectopic pregnancy in this case.
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