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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because earphones are not used in the Rinne test. The Rinne test compares air conduction and bone conduction of sound using a tuning fork.

Choice B Reason: This is incorrect because electrodes are not used in the Rinne test. Electrodes are used in electroencephalography (EEG), which measures brain activity.

Choice C Reason: This is incorrect because a probe is not used in the Rinne test. A probe is used in tympanometry, which measures the pressure and mobility of the eardrum.

Choice D Reason: This is correct because a tuning fork is used in the Rinne test. The tuning fork is placed on the mastoid process behind the ear and then moved near the ear canal to compare the sound perception.

A. "Ménière's disease is caused by an allergic response." B. "This medication can help offset the nauseous feeling." C. "Anticholinergics will help you rest." D. "This medication can help reduce vomiting episodes."

Correct Answer is A

Explanation

Choice A Reason: This is incorrect because Ménière's disease is not caused by an allergic response. Ménière's disease is a disorder of the inner ear that causes vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. The exact cause of Ménière's disease is unknown, but it may be related to fluid imbalance, infection, trauma, or autoimmune reaction.

Choice B Reason: This is correct because diphenhydramine can help offset the nauseous feeling. Diphenhydramine is an antihistamine that blocks histamine receptors in the brain and inner ear, which can reduce nausea and vomiting associated with vertigo.

Choice C Reason: This is correct because anticholinergics will help you rest. Anticholinergics are a class of drugs that block acetylcholine receptors in the brain and body, which can have sedative effects and reduce motion sickness. Diphenhydramine has anticholinergic properties.

Choice D Reason: This is correct because diphenhydramine can help reduce vomiting episodes. As mentioned above, diphenhydramine can reduce nausea and vomiting by blocking histamine receptors in the brain and inner ear.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A client admitted with an acute exacerbation of Ménière's disease asks the student nurse why he was prescribed diphenhydramine. Which response by the student nurse requires correction by the primary nurse?

Correct Answer is A

Explanation

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