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 B
Explanation
Rationale:
A. "I will irrigate the colostomy every day.": Colostomy irrigation is used for descending or sigmoid colostomies to regulate bowel movements. It is not recommended for ascending colostomies because the stool is too liquid and unpredictable for effective irrigation.
B. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should be pink or red and moist. A purple or dusky appearance suggests compromised blood flow or ischemia and should be reported to the provider immediately as it may indicate a serious complication.
C. "I should expect my stool to be formed.": Stool from an ascending colostomy is generally liquid to semi-liquid due to the location in the digestive tract. Formed stool is more typical of descending or sigmoid colostomies, not ascending ones.
D. "I will no longer be able to eat nuts.": While some clients may choose to avoid certain foods based on personal tolerance, there is no absolute dietary restriction against nuts for colostomy clients unless otherwise advised.
Correct Answer is B
Explanation
Rationale:
A. "I will position my arms away from my body when pushing an object.": Keeping the arms close to the body provides better leverage and reduces strain on the muscles and joints. Extending arms away increases risk of injury.
B. "I will position my body to face an object, so I avoid twisting: Facing the object directly helps maintain proper spinal alignment and reduces the risk of back injury by minimizing twisting motions during lifting or pushing.
C. "I will position my legs close together before lifting.": Keeping legs close together decreases stability and increases risk of losing balance. A wider stance improves balance and distributes weight evenly during lifting.
D. "I will position objects away from my body before lifting them.": Objects should be held close to the body to reduce strain on the back and arms. Holding objects away increases lever arm forces and injury risk.
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