A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

"My grandkids are so excited to have me coming home!"

"I am going to have my daughter scoop the cat litter box."

"All my friends and neighbors are planning a party for me."

"I hope I can get my water turned back on when I get home."

Answer and Explanation

The Correct Answer is B

A. The excitement of family does not indicate an infection risk. Emotional support can aid recovery.

B. Handling cat litter, which can contain bacteria, is a potential source of infection. Given the client's sternal wound, exposure to such bacteria increases the risk of infection, including sepsis.

C. Attending a party may present social interaction risks, but it is not as directly related to infection risk as handling cat litter.

D. Having the water turned on does not pose a significant risk for infection or sepsis.

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Correct Answer is B

Explanation

A. A small, mobile, rubbery lump is often benign, such as a fibroadenoma.

B. A nontender, fixed breast nodule is concerning for malignancy, and further evaluation is necessary, such as imaging or biopsy.

C. Tender, bilateral nodules are commonly seen in benign conditions like fibrocystic breast changes, especially related to the menstrual cycle.

D. A lump that changes in size before menstruation is also typical of benign conditions like fibrocystic changes.

A. Client with serum phosphorus level of 4.5 mg/dL. B. Client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. C. Client with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping. D. Client with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water.

Correct Answer is B

Explanation

A. Client with serum phosphorus level of 4.5 mg/dL: This is within the normal range for phosphorus (2.5-4.5 mg/dL), and the client does not require immediate assessment.

B. Client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes: This is the correct answer. A magnesium level of 1.1 mEq/L is below the normal range (1.5-2.5 mEq/L), and symptoms like tremors and hyperactive reflexes indicate hypomagnesemia, which can lead to serious complications such as arrhythmias.

C. Client with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping: A potassium level of 5.0 mEq/L is within the normal range (3.5-5.0 mEq/L), so this client does not need immediate intervention.

D. Client with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water: A sodium level of 145 mEq/L is at the upper end of normal (135-145 mEq/L), and the symptoms are likely due to dehydration or a normal response.

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A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

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Naxlex Comprehensive Predictor Exams

Which assessment finding in a 36-year-old client is most indicative for further evaluation?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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