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 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.
Correct Answer is B
Explanation
Choice A reason: Petechiae are small red or purple spots caused by bleeding into the skin, typically associated with platelet disorders, and are not a direct indicator of SBP.
Choice B reason: Increased abdominal pain is a common symptom of SBP, as the condition causes inflammation and irritation of the peritoneum, which can lead to significant discomfort.
Choice C reason: Jaundice is a sign of liver dysfunction but is not specific to SBP. It results from high levels of bilirubin in the blood and can occur in various liver diseases.
Choice D reason: Blood in emesis (vomiting) may indicate gastrointestinal bleeding, which can be a complication of cirrhosis but is not specific to SBP.
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