The nurse is caring for an older adult who was admitted with a urinary tract infection and is now exhibiting signs of severe inflammatory response syndrome (SIRS). Which collaborative care goal(s) should the nurse include in the plan of care? Select all that apply.
Reduce white blood cell count.
Body temperature within normal limits.
Decrease blood pressure.
Negative urine culture.
Incision free of exudate.
Correct Answer : B,D,E
Choice A rationale: Reducing the white blood cell count is not a goal of SIRS treatment, as it would impair the immune system's ability to fight the infection.
Choice B rationale: Maintaining body temperature within normal limits is a collaborative goal to address the signs of SIRS.
Choice C rationale: Decreasing blood pressure is not typically a goal in the management of SIRS; the focus is on maintaining adequate perfusion.
Choice D rationale: Achieving a negative urine culture is a collaborative goal to address the underlying urinary tract infection.
Choice E rationale: incision free of exudate is an indicator of resolving infection and inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Determining which foods aggravate the client's symptoms is beyond the scope of the UAP and should be addressed by licensed healthcare providers. Choice B rationale: Elevating the head of the bed before the client begins to eat helps prevent reflux in clients with hiatal hernia, and it's a task that can be delegated to the UAP.
Choice C rationale: Teaching the client about the need to eat small, frequent meals is a nursing responsibility and should be performed by a licensed nurse.
Choice D rationale: Assessing the client for heartburn or a feeling of fullness after eating is a nursing responsibility and requires a licensed nurse's judgment.
Correct Answer is B
Explanation
Choice A rationale: While the client with the gunshot wound requires attention, the client with a collapsed left lower lung and 100 ml drainage in a chest tube collection container is at immediate risk for respiratory compromise.
Choice B rationale: The client who fell from a ladder with a collapsed left lower lung and 100 ml drainage in a chest tube collection container requires the most immediate intervention to address potential respiratory distress.
Choice C rationale: The client post-mastectomy with 50 ml of serosanguineous fluid in a Jackson-Pratt drain may need attention, but the respiratory distress in the other client takes precedence.
Choice D rationale: The client who had an abdominal perineal resection with no drainage on the dressing and reporting chills may require attention, but the respiratory distress in the other client is a more urgent concern.
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