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 e to the client's
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale:
• Antibiotic: Administering an antibiotic addresses the underlying infection, which is likely causing the fever, low blood pressure, and altered mental status. Prompt antibiotic treatment reduces the risk of progression to septic shock. Early intervention improves patient outcomes in suspected sepsis.
• Antipyretic: An antipyretic helps reduce fever but does not treat the underlying infection. Lowering the temperature alone would not address the systemic inflammatory response seen in sepsis. This option does not prevent clinical deterioration.
• Anti-anxiety medication: An anti-anxiety medication may temporarily calm the patient but can worsen confusion and mask signs of deterioration. It does not treat the infection or improve hemodynamic status. This is inappropriate in suspected sepsis.
• Suspected surgical site infection and sepsis: The inflamed, draining surgical wound, fever, hypotension, and high WBC strongly indicate a developing infection. Mental status changes are also typical in sepsis. This makes infection the most urgent concern requiring antibiotic therapy.
• Elevated temperature and heart rate: While these signs are concerning, they are common with many conditions and not specific to sepsis. They are part of the clinical picture but not the driving reason for immediate antibiotic treatment.
• History of Parkinson’s disease and confusion: The confusion may partly relate to Parkinson’s or sensory impairment, but acute mental status changes with fever and hypotension suggest sepsis. Parkinson’s is chronic and not the immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.
B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.
C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.
D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.
Correct Answer is A
Explanation
Rationale:
A. The weights apply a pulling force continuously: Buck’s traction is a form of skin traction used to immobilize fractures and reduce muscle spasms. The weights must hang freely and provide a constant pulling force to maintain alignment and promote healing.
B. The boot allows active leg movement: In Buck’s traction, the affected leg should be immobilized. Active movement would interfere with the consistent traction force and compromise the effectiveness of the treatment.
C. The footplate rests against the foot of the bed: The client’s foot should not press against the bedframe or footplate, as this can counteract the traction force and cause improper alignment. There should be adequate space for traction to be effective.
D. The weights are just touching the floor: Weights should hang freely and never touch the floor. If they rest on the floor, the traction force is lost, defeating the purpose of the setup and potentially leading to complications.
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