A client with an infected spider bite is receiving IV antibiotics through a central venous catheter. The practical nurse (PN) observes that the client is weak, pale, and diaphoretic. Which additional finding should the PN report immediately to the charge nurse?
Red streaks from wound.
Urine output 20 mL/hour.
Purulent wound drainage.
Blood pressure 100/60 mm Hg.
The Correct Answer is B
A. Red streaks from wound: Could indicate lymphangitis but not immediately life-threatening.
B. Urine output 20 mL/hour: Indicates possible septic shock with decreased renal perfusion - urgent finding.
C. Purulent wound drainage: Suggests infection but expected in an infected bite; not immediately life-threatening.
D. Blood pressure 100/60 mm Hg: Low-normal BP; not yet critical unless accompanied by other shock signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Give 4 oz (120 mL) of apple juice:
Diaphoresis, confusion, and “not feeling right” indicate hypoglycemia. Rapid-acting carbohydrates should be given immediately if the client can swallow.
B. Administer glucagon 0.5 mg IM:
Used if the client is unconscious or unable to swallow safely.
C. Assess temperature:
Does not address the immediate risk of hypoglycemia.
D. Evaluate deep tendon reflexes:
Not relevant to urgent management of suspected hypoglycemia.
Correct Answer is A
Explanation
A. Obtain a specimen of urethral drainage for culture:
Symptoms suggest possible gonorrhea or chlamydia; culture needed for diagnosis and treatment guidance.
B. Identify all sexual partners in the last four days:
Partner notification is important but follows confirmed diagnosis.
C. Observe the perineal area for a chancroid-like lesion:
Chancroid presents differently; symptoms point to urethritis.
D. Assess for perineal itching, erythema, and excoriation:
These are signs of fungal infection or dermatitis, not primary concern here.
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