A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

Localized edema.

An increase in neutrophils.

An increase in platelets.

Bradycardia.

An increase in RBCS.

Answer and Explanation

Correct Answer : A,B

Choice A rationale:
Localized edema is a common sign of infection. The body sends extra fluid to the area as part of the inflammatory response.
Choice B rationale:
An increase in neutrophils, a type of white blood cell, is a common response to infection. Neutrophils are part of the body’s immune response and work to fight off invading bacteria.
Choice C rationale:
An increase in platelets is not typically associated with infection. Platelets are involved in blood clotting, not the immune response.
Choice D rationale:
Bradycardia, or a slow heart rate, is not typically associated with infection. Infection usually causes an increased heart rate, not a decreased one.
Choice E rationale:
An increase in RBCs is not typically associated with infection. RBCs carry oxygen around the body, but their number does not usually change in response to infection.

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Correct Answer is A

Explanation

Choice A rationale:
A decrease in heart rate is an indication of adequate fluid replacement. As fluid volume is restored, the heart does not have to work as hard to pump blood, so the heart rate decreases.
Choice B rationale:
Blood pressure is not a reliable indicator of fluid volume status. It can be influenced by many factors, including pain, anxiety, and medications.
Choice C rationale:
Weight is not a reliable indicator of fluid volume status in the short term. It can take several days for changes in fluid volume to be reflected in weight.
Choice D rationale:
Urine output is a good indicator of kidney function, but it is not a reliable indicator of fluid volume status. Many factors can influence urine output, including kidney function, fluid intake, and medications.

A. "The bright light in this room is really bothering me.”. B. "It's hard to see with a patch on one eye. I'm afraid of falling.”. C. "I need something for the pain in my eye. I can't stand it.”. D. "My eye really itches, but I'm trying not to rub it.”.

Correct Answer is C

Explanation

Choice A rationale:
Sensitivity to light is a common postoperative symptom after cataract surgery.
Choice B rationale:
Difficulty with depth perception is expected when one eye is patched.
Choice C rationale:
Severe pain is not a normal postoperative symptom and should be reported to the provider.
Choice D rationale:
Itching is a common postoperative symptom after cataract surgery.

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A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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