The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?
Evaluate pupil reactions every shift
Assess temperature every 4 hours
Monitor for cyanosis
Check reflexes
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While it's important to monitor WBC levels for overall health, it is not specifically related to the administration of levodopa/carbidopa for Parkinson's disease.
Choice B reason: Blood pressure should be checked before administering levodopa/carbidopa as these medications can affect blood pressure, potentially causing hypotension.
Choice C reason: Assessing for bleeding is a general nursing action but not specifically related to levodopa/carbidopa administration.
Choice D reason: Providing a high-protein snack can actually interfere with the absorption of levodopa and should be avoided at the time of medication administration.
Correct Answer is B
Explanation
Choice A reason: While individuals with rheumatoid arthritis may have an increased risk of infection due to the disease itself or the use of immunosuppressive medications, it does not pose as high a risk as intravenous lines for sepsis.
Choice B reason: A peripherally inserted central catheter (PICC) line, especially when used for total parenteral nutrition (TPN), presents a significant risk for infection due to the direct access to the bloodstream, making this client at the highest risk for sepsis.
Choice C reason: Asthma and bronchitis can lead to respiratory infections, but these conditions do not typically result in sepsis unless the infection becomes severe and systemic.
Choice D reason: Renal calculi (kidney stones) can cause infections; however, they are less likely to lead to sepsis compared to a central line.
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