The nurse is admitting a client diagnosed with a urinary tract infection (UTI) and sepsis. Which intervention would the nurse consider a priority?

Assess temperature.

Monitor urine output.

Administer antibiotics.

Evaluate current CBC (Complete Blood Count).

Answer and Explanation

The Correct Answer is C

Choice A reason: While assessing temperature is important for monitoring infection, it is not the immediate priority in the treatment of UTI and sepsis.

Choice B reason: Monitoring urine output is crucial for a UTI but does not address the systemic infection that sepsis represents.

Choice C reason: Administering antibiotics is the most critical intervention for a client with sepsis due to a UTI, as it directly addresses the underlying infection and can be life-saving.

Choice D reason: Evaluating the current CBC is important for understanding the client's baseline and response to infection but is secondary to the administration of antibiotics.

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Correct Answer is A

Explanation

Choice A reason: Sodium restriction is a standard intervention in the management of cirrhosis, particularly when there is fluid retention leading to a distended abdomen (ascites) and weight gain.

Choice B reason: Encouraging fluids would not be appropriate for a client with cirrhosis who is already experiencing fluid overload, as indicated by a distended abdomen and weight gain.

Choice C reason: Checking lipase levels is associated with pancreatic function and would not be a direct intervention based on the symptoms of cirrhosis presented.

Choice D reason: Pancrealipase is used to aid digestion in patients with pancreatic insufficiency and is not related to the management of cirrhosis symptoms such as ascites and dyspnea.

A. Evaluate pupil reactions every shift B. Assess temperature every 4 hours C. Monitor for cyanosis D. Check reflexes

Correct Answer is C

Explanation

Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.

Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.

Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.

Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.

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The nurse is admitting a client diagnosed with a urinary tract infection (UTI) and sepsis. Which intervention would the nurse consider a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Assessment of a client with cirrhosis reveals a distended abdomen, weight gain, and dyspnea. Based on this information, what interventions would the nurse include in this client's plan of care?

Correct Answer is A

Explanation

The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

Correct Answer is C

Explanation

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