A client presents with both a low-grade fever and suspected tissue injury.
How should a nurse prioritize the potential diagnoses?
Evaluate the tissue injury for complications.
Administer fluids for hydration.
Request labs for hematology profiles.
Treat the fever with antipyretics.
The Correct Answer is A
Choice A rationale
Tissue injury represents a breach in the primary defense mechanism of the body and can lead to localized or systemic infection. Prioritizing the evaluation of the injury allows the nurse to identify signs of necrosis, purulence, or cellulitis that could be the source of the low grade fever. Tissue integrity is fundamental to preventing sepsis. Monitoring for complications such as compartment syndrome or gangrene is more critical than treating a mild temperature elevation that may be a normal inflammatory response.
Choice B rationale
Hydration is important for maintaining perfusion to injured tissues and supporting metabolic processes during healing. However, it is a supportive measure rather than a primary diagnostic priority. While fluid loss can occur through large wounds, a low grade fever alone does not usually indicate a severe fluid volume deficit. The nurse must first understand the nature and severity of the tissue injury to determine the appropriate rate and type of fluid resuscitation required for the client.
Choice C rationale
Requesting labs is a collaborative intervention that provides objective data on the inflammatory response and potential infection. While hematology profiles like White Blood Cell counts are useful, the physical assessment of the tissue injury provides more immediate information regarding the localized state of the wound. Labs confirm what the physical assessment suggests. The nurse should prioritize the direct inspection of the site to guide the urgency of laboratory testing and other medical orders.
Choice D rationale
A low grade fever is often a beneficial physiological response that enhances immune function and inhibits pathogen replication. Treating it immediately with antipyretics can mask the clinical progression of an underlying infection. Fever is a symptom, not the primary pathology. The focus should remain on identifying and managing the cause of the fever, which in this case is likely the tissue injury. Antipyretics should be reserved for higher temperatures or when the client experiences significant discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The use of herbal supplements can pose risks, such as increased bleeding if the patient takes ginkgo or garlic, or interactions with anesthesia. However, these are generally manageable through preoperative screening and temporary cessation of the supplements. While important, they do not represent the same level of systemic risk for major postoperative complications, such as myocardial infarction or heart failure, as a documented history of established cardiovascular disease does in the elderly population.
Choice B rationale
Being under age 40 is actually a protective factor rather than a risk factor for complications. Younger patients typically have better physiological reserves, faster healing rates, and fewer comorbidities compared to older adults. Most complications in total knee arthroplasty are associated with advanced age, which often brings decreased bone density and impaired cardiovascular function. Therefore, youth generally correlates with better outcomes and a lower likelihood of experiencing systemic complications during or after the surgical procedure.
Choice C rationale
A vegetarian diet is not a significant risk factor for surgical complications, provided the patient maintains adequate protein and iron intake for wound healing. While extreme nutritional deficiencies can impair recovery, most vegetarians meet their nutritional needs through varied food sources. Protein is essential for collagen synthesis, but a meat-free diet does not inherently predispose a patient to poor surgical outcomes unless it is poorly managed and results in severe anemia or protein-energy malnutrition.
Choice D rationale
A history of heart disease is a major risk factor for complications during and after total knee arthroplasty. The stress of surgery and anesthesia can strain the cardiovascular system, leading to arrhythmias, myocardial ischemia, or heart failure. Furthermore, heart disease often necessitates the use of anticoagulants, which complicates intraoperative bleeding management and postoperative DVT prophylaxis. Patients with cardiac issues have a reduced ability to compensate for the hemodynamic shifts that occur during major orthopedic operations.
Correct Answer is C
Explanation
Choice A rationale
The tetanus vaccine is highly specific to preventing the neurological manifestations caused by the toxin of one particular bacterium. It does not provide a generalized mechanism to stop the spread of various other opportunistic infections to different body systems. Burn wounds are indeed prone to multiple types of bacterial colonization, but protection against systemic spread of common flora like Staphylococcus or Pseudomonas requires different interventions, such as topical antimicrobials or systemic antibiotics rather than a toxoid.
Choice B rationale
Vaccines are designed to stimulate the immune system, but the tetanus toxoid specifically triggers the production of antibodies against the tetanospasmin toxin produced by Clostridium tetani. It is not an antiviral intervention and does not improve the body's general immune response against viral pathogens like influenza or herpes. Burn patients may be at risk for viral complications, but the rationale for the tetanus vaccine is strictly focused on anaerobic bacterial toxin protection in contaminated wounds.
Choice C rationale
Burn injuries create an environment of necrotic, anaerobic tissue which is ideal for the growth of Clostridium tetani. The tetanus vaccine provides active immunization by introducing a modified toxin that stimulates the patient's B-cells to produce specific antitoxin antibodies. This is a standard part of burn management because the spores are ubiquitous in the environment and can easily contaminate a wound. Maintaining an up-to-date immunization status is critical for preventing this potentially fatal neuromuscular disease.
Choice D rationale
While the tetanus vaccine prevents the specific disease caused by one bacterium, it is not a broad-spectrum prophylactic measure against the wide variety of other bacteria that can infect burn wounds. Burn wound sepsis is usually caused by gram-positive and gram-negative organisms that are not affected by tetanus immunization. The vaccine is administered solely because of the specific risk of tetanus in deep or contaminated wounds, rather than as a general preventative for all wound infections.
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