The nurse is reviewing laboratory results for a client with sepsis. The results are as follows:
- WBC: 11,000/mm³ (normal range: 5,000-10,000 mm³)
- PaO2: 90 mm Hg (normal range: 80-100 mm Hg)
- aPTT: 50 seconds (normal range: 30-40 seconds)
- Platelet count: 98,000/mm³ (normal range: 150,000-400,000 mm³)
What is the nurse's priority action?
Assess for hematuria.
Monitor temperature.
Evaluate skin turgor.
Administer heparin.
The Correct Answer is D
Choice A reason: Assessing for hematuria is important but not the priority action. Hematuria can be a symptom of various conditions and does not directly address the abnormal laboratory results.
Choice B reason: Monitoring temperature is a routine action in sepsis management but does not address the immediate concern of the abnormal laboratory results, specifically the elevated aPTT and low platelet count.
Choice C reason: Evaluating skin turgor is a method to assess dehydration, which is not the immediate concern indicated by the laboratory results.
Choice D reason: The elevated aPTT and low platelet count suggest a potential coagulopathy, which could be a sign of disseminated intravascular coagulation (DIC), a complication of sepsis. Administering heparin may be part of the treatment for DIC to prevent further clotting and is a priority action in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A reason: Tachycardia and weight gain are not typically associated with low T4 levels. Tachycardia and weight loss are more commonly seen in hyperthyroidism, where T4 levels would be elevated.
Choice B reason: Diarrhea and hypoglycemia are not directly related to low T4 levels. Diarrhea can be a symptom of hyperthyroidism, while hypoglycemia is not commonly associated with thyroid function.
Choice C reason: Hypotension and periorbital edema are findings that can be associated with hypothyroidism, which is consistent with the low T4 level of 2.9 mcg/dL. Hypothyroidism can lead to reduced cardiac output and systemic vascular resistance, causing hypotension. Periorbital edema is also a common sign of hypothyroidism due to mucopolysaccharide deposition in the skin.
Choice D reason: Tremors and dyskinesias are more commonly associated with hyperthyroidism, not hypothyroidism. Elevated levels of thyroid hormones can lead to these neurological symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.