The nurse is assessing a client admitted for treatment of pneumonia and possible sepsis. Which information is most important for the nurse to report?
Serum lactate level 3.9 mmol/L (normal range: 0.5-2 mmol/L)
Vital signs: Temperature 100°F, Heart rate 88 bpm, Respiratory rate 22 breaths/min, Blood pressure 124/72 mmHg
Pulse oximetry 96% on oxygen at 2 L/min via nasal cannula
Breath sounds with rhonchi bilaterally
The Correct Answer is A
Choice A reason: The serum lactate level of 3.9 mmol/L is significantly higher than the normal range of 0.5-2 mmol/L. This is a critical value to report as it indicates a high likelihood of sepsis, which is a life-threatening condition requiring immediate intervention. Elevated lactate levels suggest that the tissues are not adequately oxygenated, a state known as tissue hypoxia, which is a hallmark of sepsis.
Choice B reason: While the vital signs show a slight fever (100°F), the heart rate, respiratory rate, and blood pressure are within normal limits for an adult and do not indicate an immediate life-threatening condition.
Choice C reason: A pulse oximetry reading of 96% on supplemental oxygen is within the acceptable range, indicating adequate oxygen saturation and not a direct sign of sepsis.
Choice D reason: The presence of rhonchi bilaterally suggests airway obstruction due to mucus, which can be associated with pneumonia. However, this finding alone does not carry the same immediate risk of morbidity and mortality as an elevated lactate level indicative of sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A reason: Resting tremor is a classic symptom of Parkinson's disease and is one of the primary diagnostic criteria.
Choice B reason : Limited range of motion is not specific to Parkinson's disease and can be caused by various conditions.
Choice C reason : Hypertension is not a diagnostic criterion for Parkinson's disease.
Choice D reason : Difficulty rising to stand is associated with the bradykinesia seen in Parkinson's disease, making it a relevant symptom for diagnosis.
Choice E reason : Diarrhea is not typically associated with Parkinson's disease and is not a diagnostic criterion.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Slowed movement when rising from a chair is a common symptom of Parkinson's disease, known as bradykinesia.
Choice B reason: Chronic diarrhea is not typically associated with Parkinson's disease.
Choice C reason: Difficulty swallowing, or dysphagia, is a common issue in Parkinson's disease due to impaired muscle control.
Choice D reason: A shuffling gait is characteristic of Parkinson's disease, often referred to as "festinating gait."
Choice E reason: Lower extremity edema is not a typical symptom of Parkinson's disease and may indicate other health issues.
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