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 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.
Correct Answer is A
Explanation
Rationale for Choice A:
Tachypnea and restlessness are common signs of respiratory distress, which is a potential complication of pneumonia. These signs indicate that the client's oxygenation may be compromised and require immediate attention.
Rationale for Choice B:
Weight loss of 1 pound since yesterday is a non-specific finding and could be due to a variety of factors, including poor appetite, dehydration, or muscle wasting. While weight loss can be a symptom of HIV infection, it is not an acute sign that requires immediate prioritization in this case.
Rationale for Choice C:
Frequent loose stools can be a symptom of HIV infection or a side effect of certain medications. However, it is not an acute sign that requires immediate prioritization in this case, especially in the context of the client's respiratory distress.
Rationale for Choice D:
An oral temperature of 100°F is a low-grade fever and is not a specific indicator of any serious condition. While fever can be a symptom of pneumonia, it is not the most concerning finding in this case.
Therefore, based on the client's presenting symptoms, tachypnea and restlessness are the most concerning findings and should be prioritized by the nurse.
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