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 ["1370"]
Explanation
To calculate the total output for the client, we need to add up all the individual outputs:
- The client voided 400 mL at 1100.
- The client voided 350 mL at 1430.
- The closed chest drainage system increased from 155 mL to 175 mL, which is an increase of 20 mL.
- The NG tube has 575 mL in the drainage container.
- The Jackson-Pratt drainage tube has 25 mL.
Adding all these amounts together, the total output that the nurse should record in the medical record is 1370 mL.
Here’s the calculation:
400 mL + 350 mL + (175 mL - 155 mL) + 575 mL + 25 mL = 1370 mL400mL+350mL+(175mL−155mL)+575mL+25mL=1370mL
So, the nurse should record a total output of 1370 mL in the medical record for the client.
Correct Answer is A
Explanation
Choice A rationale:
Phenytoin is an anticonvulsant medication that is typically used long-term to control seizures. It is not a medication that can be stopped abruptly, as this can lead to the recurrence of seizures or even status epilepticus, a life-threatening condition characterized by continuous seizure activity.
The client's statement, "I'll be glad when I can stop taking this medicine," indicates a lack of understanding about the long- term nature of phenytoin therapy and the potential risks associated with stopping the medication prematurely.
Further teaching is needed to emphasize the importance of medication adherence and the potential consequences of non- adherence.
Choice B rationale:
Phenytoin can cause gingival hyperplasia (overgrowth of gum tissue), so it is important for clients taking this medication to see a dentist regularly for checkups and cleanings.
The client's statement, "I have made an appointment to see my dentist next week," indicates an understanding of this potential side effect and the need for regular dental care.
Choice C rationale:
Phenytoin has a narrow therapeutic index, meaning that there is a small difference between the effective dose and the toxic dose.
Switching brands of phenytoin can lead to changes in blood levels of the medication, which could potentially result in therapeutic failure or toxicity.
The client's statement, "I know that I cannot switch brands of this medication," indicates an understanding of this important safety consideration.
Choice D rationale:
Phenytoin can interact with many other medications, including over-the-counter medications and herbal supplements.
It is important for clients taking phenytoin to notify their doctor before taking any other medications to avoid potential drug interactions.
The client's statement, "I will notify my doctor before taking any other medications," indicates an understanding of this potential risk.
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