A female client admitted with possible pneumonia and systemic inflammatory response syndrome (SIRS) is manifesting low oxygen saturation rates. Which additional finding(s) associated with SIRS should the nurse report to the health care provider (HCP)? Select all that apply.

Reference Range

White Blood Cell [5,000 to 10,000/mm3 (5 to 10 10/L)]

Hemoglobin [12 to 16 g/dL (7.45 to 9.93 mmol/L)]

Respiratory rate of 26 breaths/minute.

Heart rate of 112 beats/minute.

Temperature of 96.1° F (35.6°C).

White blood count of 14,000/mm3 (14 x 109/L).

Hemoglobin of 12.8 gram/dL (7.94 mmol/L).

Answer and Explanation

Correct Answer : A,B,C,D

A. Respiratory rate of 26 breaths/minute. A respiratory rate ≥22 breaths/minute meets the SIRS criteria and indicates systemic inflammation or respiratory distress. In pneumonia, increased breathing effort may result from hypoxia or infection-related metabolic demands. Persistent tachypnea suggests worsening sepsis and requires urgent intervention.
B. Heart rate of 112 beats/minute. A heart rate ≥90 beats/minute is a SIRS criterion, often caused by infection, hypoxia, or systemic inflammation. In pneumonia, tachycardia may result from fever, pain, or compensatory mechanisms due to decreased oxygenation. An elevated heart rate in sepsis may indicate progressing hemodynamic instability.
C. Temperature of 96.1° F (35.6°C). Hypothermia (<96.8°F/36°C) is a SIRS criterion and may indicate severe sepsis or systemic inflammatory response. While fever is a common response, low temperature suggests immune system dysfunction. Hypothermia in sepsis is linked to poor prognosis and increased mortality risk.
D. White blood count of 14,000/mm³ (14 x 10⁹/L). A WBC >12,000/mm³ or <4,000/mm³ meets SIRS criteria and indicates infection-related immune activation. Elevated WBCs suggest an active inflammatory response to pneumonia. A rising WBC count may indicate worsening infection or ineffective immune control.
E. Hemoglobin of 12.8 gram/dL (7.94 mmol/L). Hemoglobin levels within the normal range (12-16 g/dL) do not indicate SIRS or sepsis progression. While anemia can develop in chronic illness or bleeding, this value does not contribute to SIRS classification. Monitoring oxygenation and perfusion is more relevant in pneumonia cases.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Determine patellar tendon reflex response. The patellar reflex (knee jerk) assesses function of the L2-L4 spinal nerves, which are below the level of injury (C8-T1) and do not provide information about upper extremity function. While deep tendon reflexes are important, they do not help assess function at the suspected injury level.
B. Check the urinary bladder for distention. Bladder function is controlled by the sacral spinal nerves (S2-S4), which are much lower than the injury level. While bladder dysfunction is common in spinal cord injuries, it does not assess C8-T1 nerve function specifically.
C. Ask the client to grasp an object or form a fist. The C8 and T1 spinal nerves control hand and finger movements, including grip strength. Testing the client’s ability to grasp an object or form a fist helps assess fine motor function and nerve integrity at the injury level. This is the most appropriate way to determine function in the lower cervical and upper thoracic spinal nerves.
D. Apply resistance while the client lifts the legs. Leg movement is controlled by the lumbar and sacral spinal nerves (L2-S2), which are below the injury level. Assessing leg strength does not provide relevant information about C8-T1 function.

A. Increase the fraction of inspired oxygen B. Collect equipment for a needle aspiration C. Replace the ventilator D. Measure the nasogastric tube output E. Place the client in Trendelenburg

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Increase the fraction of inspired oxygen (FiO₂). The client has severe COVID pneumonia and is on mechanical ventilation with high inspiratory pressures, suggesting acute respiratory distress syndrome (ARDS). Increasing FiO₂ is indicated if oxygenation is inadequate (e.g., low PaO₂ or SpO₂). However, oxygen toxicity should be avoided, so adjustments should be made based on arterial blood gases (ABGs) and oxygen saturation.
Collect equipment for a needle aspiration. Needle aspiration is typically used for pneumothorax management, but there is no mention of clinical signs such as sudden hypotension, absent breath sounds, or tracheal deviation. While ventilated COVID-19 patients are at risk for barotrauma, this procedure is not justified without evidence of pneumothorax.
Replace the ventilator. There is no indication that the ventilator is malfunctioning or that the settings are inappropriate. If ventilation issues arise (e.g., high plateau pressures, auto-PEEP, or ventilator asynchrony), adjustments to settings, sedation, or lung-protective strategies should be considered before replacing the ventilator.
Measure the nasogastric tube output. The client is intubated and sedated, meaning they cannot protect their airway or tolerate oral intake. A nasogastric (NG) tube is commonly placed for gastric decompression and feeding. Monitoring NG output is essential to assess for gastrointestinal bleeding, ileus, or high residual volumes, which can affect feeding tolerance.
Place the client in Trendelenburg. The Trendelenburg position increases the risk of aspiration, impairs lung expansion, and worsens ventilation-perfusion mismatch, especially in ARDS patients. Instead, prone positioning is often preferred in severe COVID pneumonia to improve oxygenation and alveolar recruitment.

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Naxlex Comprehensive Predictor Exams

A client with a gunshot wound is brought to the emergency department (ED) with a bullet entry at the spinal level of C8 and T1.The client is able to move the upper arms. To further assess the client's spinal nerve function, which action should the nurse implement?

Correct Answer is C

Explanation

Exhibits Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

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