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 C

Explanation

A. Epinephrine is used in cases of severe allergic reactions or anaphylaxis, and while it may be appropriate in treating angioedema, the first priority is to ensure the airway is clear and that the client can breathe. Administering epinephrine may be part of the treatment plan but should follow securing the airway and calling for immediate advanced help.

B. This is not appropriate because angioedema can be life-threatening and can rapidly progress to airway obstruction. Reassurance without action would delay necessary interventions and could jeopardize the client’s safety.

C. In cases of angioedema, airway obstruction is the most dangerous complication, as it can lead to asphyxiation. The nurse's first priority is to ensure that the patient's airway remains open and clear. The nurse should immediately call the Rapid Response Team (RRT) for urgent medical intervention, which may include medications (like epinephrine), intubation, or other interventions. Ensuring the airway is open and calling for advanced help are the most critical first steps in managing severe cases of angioedema.

D. While oxygen therapy may be appropriate if the client shows signs of respiratory distress or hypoxia, the immediate concern is securing the airway. Oxygen may be needed after ensuring the airway is open, but the priority is to avoid airway obstruction first. The nurse should secure the airway and then administer oxygen if needed.

A. Instruct the client to drink water. B. Hold the next dose. C. Initiate oxygen therapy. D. Administer PRN acetaminophen.

Correct Answer is D

Explanation

A. Drinking water is not likely to alleviate the headache caused by the nitrate.

B. Holding the next dose is not necessary unless the headache becomes severe or is associated with other symptoms.

C. Initiating oxygen therapy is unnecessary for a headache caused by nitrate use.

D. A headache is a common side effect of nitrate administration due to the vasodilation effect. Administering PRN acetaminophen can help relieve the headache.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is in the hospital and has received two doses of an angiotensin-converting enzyme (ACE) inhibitor for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below. What action by the nurse is most appropriate?

Correct Answer is C

Explanation

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

Correct Answer is D

Explanation

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?

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