Which client does the nurse identify as having the greatest risk for the development of sepsis?
A 59-year-old with rheumatoid arthritis.
A 71-year-old with a PICC line for TPN.
A 14-year-old with asthma and bronchitis.
A 39-year-old with renal calculi.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: An oral temperature of 99.8°F (37.7°C) post-operatively may not be unusual and does not necessarily indicate a complication.
Choice B reason: A post-operative hemoglobin of 10.9 g/dL is slightly below the normal range but may be expected after surgery due to blood loss.
Choice C reason: A client reporting a pressure sensation at the incision site could indicate bleeding or swelling under the incision, which can be a sign of a hematoma, a serious complication that needs immediate attention.
Choice D reason: Pain at the incision site is expected post-operatively and can be managed with pain relief measures.
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.
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