Which of the following is the most reliable early indicator of infection in a client with low WBC?
Fever
Chills
Tachycardia
Dyspnea
The Correct Answer is A
Choice A rationale:
Fever is the most reliable early indicator of infection in a client with low WBC because it is a direct physiologic response to the presence of pathogens. When the body detects an infection, it releases pyrogens, which act on the hypothalamus to raise the body's temperature. This elevated temperature helps to create an environment that is less hospitable to bacteria and viruses, and it also stimulates the immune system to fight the infection.
In clients with low WBC, the immune system is already compromised, so the fever response may be even more pronounced. It's important to note that even a slight elevation in temperature (as low as 100.4°F or 38°C) can be significant in these clients.
Choice B rationale:
Chills can also be a sign of infection, but they are not as specific as fever. Chills can occur for other reasons, such as exposure to cold or anxiety.
Choice C rationale:
Tachycardia, or increased heart rate, can also be a sign of infection, but it is not as reliable as fever. Tachycardia can occur for other reasons, such as dehydration, pain, or anxiety.
Choice D rationale:
Dyspnea, or shortness of breath, is not a typical early sign of infection. It is more likely to occur in later stages of infection, when the infection has spread to the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Holding the client's arms and legs from moving during a seizure can actually cause injury to the client or the nurse. The forceful muscle contractions that occur during a seizure can cause bones to break or joints to dislocate. Additionally, trying to restrain the client can increase their agitation and make the seizure worse.
Choice B rationale:
Placing the client back in bed during a seizure is not safe. The client could fall out of bed and injure themselves. It is also important to allow the client to have space to move freely during the seizure to prevent injury.
Choice C rationale:
Placing the client on their side is the safest position for a client who is having a seizure. This position helps to protect the airway and prevent aspiration. It also allows any fluids or secretions to drain out of the mouth, which can help prevent choking.
Choice D rationale:
Inserting a tongue blade into the client's mouth during a seizure is not recommended. It is a common misconception that people can swallow their tongue during a seizure. This is not possible. Inserting a tongue blade can actually cause more harm than good. It can break teeth, damage the mouth, or even block the airway.
Correct Answer is B
Explanation
Choice A rationale:
While taking colchicine with food can help minimize gastrointestinal side effects like nausea, it's not the most crucial instruction for this medication. The primary concern with colchicine is its potential for muscle toxicity.
Choice B rationale:
Colchicine can cause muscle pain, tenderness, or weakness, which can be a sign of a serious condition called rhabdomyolysis. Rhabdomyolysis involves the breakdown of muscle tissue, potentially leading to kidney damage and other complications.
It's crucial for patients to monitor for muscle pain and report it to their healthcare provider promptly if it occurs. Early detection and intervention can help prevent serious complications.
Choice C rationale:
Increased bruising is not a common side effect of colchicine. It's more frequently associated with medications that affect blood clotting, such as warfarin or aspirin.
Choice D rationale:
Grapefruit juice can interact with many medications, including colchicine. It can increase the concentration of colchicine in the bloodstream, potentially leading to toxicity.
It's crucial for patients taking colchicine to avoid grapefruit juice and other grapefruit products.
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