A client receiving parenteral nutrition by central venous access reports feeling unwell. The nurse assesses the client and suspects that the central line has become infected. Which of the following findings indicate that the client has developed a systemic infection? Select all that apply.
Edema
Purulent drainage at intravenous insertion site
Redness at insertion site
Nausea
Leukocytosis
Fever
Correct Answer : B,E,F
Choice A Reason: Edema is not a specific finding of a systemic infection, but rather a possible sign of fluid overload or impaired venous return. It can occur due to excessive infusion rate, heart failure, or obstruction of blood flow in or around the central line.
Choice B Reason: This is a correct choice. Purulent drainage at intravenous insertion site is a finding of a local infection that can spread systemically. It indicates bacterial invasion and inflammation of the skin and subcutaneous tissue around the catheter.
Choice C Reason: Redness at insertion site is a finding of a local infection that can spread systemically. It indicates increased blood flow and inflammation of the skin and subcutaneous tissue around the catheter.
Choice D Reason: Nausea is not a specific finding of a systemic infection, but rather a possible side effect of parenteral nutrition or a symptom of another condition. It can occur due to electrolyte imbalance, hyperglycemia, or gastrointestinal disorders.
Choice E Reason: This is a correct choice. Leukocytosis is a finding of a systemic infection that indicates increased production and release of white blood cells in response to infection. It can be detected by a blood test.
Choice F Reason: This is a correct choice. Fever is a finding of a systemic infection that indicates increased body temperature due to activation of the immune system and release of pyrogens. It can be measured by a thermometer.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because acute hemorrhagic stroke is not consistent with these observations. Acute hemorrhagic stroke is a sudden bleeding in the brain that can cause severe neurological deficits, such as paralysis, aphasia, or coma. It does not cause tremors, slowness, or mask-like facial expressions.
Choice B reason: This is incorrect because Alzheimer's disease is not consistent with these observations. Alzheimer's disease is a progressive degeneration of the brain that causes cognitive impairment, memory loss, and behavioral changes. It does not cause tremors, slowness, or mask-like facial expressions.
Choice C reason: This is the correct answer because Parkinson's disease is consistent with these observations. Parkinson's disease is a chronic disorder of the brain that affects movement and coordination. It causes tremors, slowness, rigidity, and postural instability, as well as mask-like facial expressions due to reduced facial muscle activity.
Choice D reason: This is incorrect because traumatic brain injury is not consistent with these observations. Traumatic brain injury is damage to the brain caused by external force, such as a blow, fall, or penetration. It can cause various neurological symptoms depending on the location and severity of the injury, but it does not typically cause tremors, slowness, or mask-like facial expressions.
Correct Answer is ["C","E","F"]
Explanation
Choice A reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not drive home after glaucoma surgery, as they will have reduced vision and increased sensitivity to light in the operated eye. The nurse should advise the client to arrange for someone else to drive them home.
Choice B reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not lay on the right side when going to bed, as this can put pressure on the operated eye and increase the risk of bleeding or infection. The nurse should advise the client to sleep on their back or on their left side.
Choice C reason: This is correct because the nurse should include this in the postoperative education to the client. The client should report flashing lights, as this can indicate a complication such as retinal detachment or vitreous hemorrhage. The nurse should instruct the client to call the provider immediately if they see flashing lights.
Choice D reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not nap on their left side when they get home, as this can cause fluid accumulation and increased intraocular pressure in the operated eye. The nurse should advise the client to elevate their head at least 30 degrees when resting.
Choice E reason: This is correct because the nurse should include this in the postoperative education to
the client. The client should avoid housework like vacuuming, as this can cause bending, lifting, or straining that can increase intraocular pressure and affect wound healing. The nurse should advise the client to limit physical activity and follow the provider's instructions on when to resume normal activities.
Choice F reason: This is correct because the nurse should include this in the postoperative education to
the client. The client may see flashes of light in the operated eye, as this is a normal phenomenon caused by stimulation of the retina by gas bubbles or fluid shifts. The nurse should reassure the client that flashes of light are normal and will subside over time.
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