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 C
Explanation
Rationale:
A. Alternative care provider: An alternative care provider may offer complementary therapies such as acupuncture or herbal treatments, but they are not specifically trained to assist with functional difficulties related to ADLs.
B. Nutritionist: A nutritionist can help manage diet and nutritional concerns, however, they do not specialize in helping clients adapt to challenges with cooking and eating caused by joint stiffness or pain.
C. Occupational therapist: An occupational therapist specializes in helping individuals adapt to physical limitations that interfere with daily living tasks. They can assess the client's needs and provide strategies, tools, and exercises to enhance independence with activities such as cooking and eating.
D. Dentist: A dentist focuses on oral health and is not involved in helping clients manage limitations in performing ADLs. This referral would be unrelated to the client's current difficulty managing tasks due to rheumatoid arthritis.
Correct Answer is D
Explanation
Rationale:
A. "You can apply counterpressure to your back with each position change.": Counterpressure is commonly used during labor to relieve back pain caused by fetal positioning. It is not relevant for postoperative cesarean pain, which is abdominal.
B. "You should change positions as little as possible.": Limiting movement after surgery can increase the risk of complications such as pneumonia and venous thromboembolism. Frequent, supported movement is encouraged to promote recovery and circulation.
C. "You should use patterned-paced breathing when changing positions.": Patterned-paced breathing is typically used during labor for pain management. While breathing techniques may offer mild comfort, they do not provide adequate support for incisional pain during movement.
D. "You can splint the incision with a pillow when changing positions.": Splinting the incision with a pillow provides support to the abdominal muscles, helping reduce tension and pain during movement. This is a safe and effective nonpharmacological strategy for post-cesarean clients.
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