A nurse is assisting in the care of a 60-year-old male client in a dialysis unit who reports fever, chills, and localized pain at the arteriovenous fistula (AVF) site.
Complete the diagram by dragging from the choices below to specify.
The Correct Answer is []
Condition: Sepsis.
2 actions:
Administer a broad-spectrum antibiotic,
Perform a swab culture of the AVF site.
2 parameters:
White blood cell count,
Blood cultures.
Rationale for correct condition: Sepsis is indicated by the client's fever, elevated heart rate, and respiratory rate, combined with signs of infection at the AVF site. Chronic conditions like diabetes and renal disease increase sepsis risk. The symptoms and history align with systemic infection spreading from the AVF site. Sepsis requires immediate intervention to prevent severe complications. Elevated temperature and infection signs suggest systemic involvement.
Rationale for actions: Administering antibiotics is crucial to control the infection. Swab culture identifies the causative organism. Indwelling catheter is unnecessary here. Aspirin does not treat infection. Bed rest alone is insufficient. Monitoring WBC count tracks infection response. Blood cultures confirm sepsis diagnosis. Creatinine is less urgent for immediate management. Blood glucose is relevant but not immediate. AVF site circumference monitors local rather than systemic infection.
Rationale for parameters: WBC count indicates immune response. Blood cultures identify bacteria, confirming sepsis. Creatinine is routine but not urgent. Blood glucose tracks diabetes control, less immediate. AVF circumference monitors local inflammation. Cellulitis is localized, not systemic. AVF thrombosis lacks systemic signs like fever. Endocarditis requires specific cardiac symptoms.
Rationale for incorrect conditions: Cellulitis does not explain systemic symptoms. AVF thrombosis lacks systemic infection signs. Endocarditis has distinct cardiac symptoms absent here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing the client in a private room with a private bathroom helps prevent the spread of the infection to other patients and ensures that the client’s wound drainage, which is likely contagious, does not contaminate shared facilities. This isolation measure is crucial in managing infectious wounds.
Choice B rationale
Discarding soiled wound care supplies outside the client's room increases the risk of contaminating common areas. Proper disposal of contaminated materials within the room is necessary to contain the infection.
Choice C rationale
Instructing visitors to perform hand hygiene for only 5 seconds is insufficient. Proper hand hygiene requires at least 20 seconds of scrubbing with soap and water or an alcohol-based hand sanitizer to effectively remove pathogens.
Choice D rationale
Administering antibiotic therapy before culturing the client's wound could interfere with the accuracy of the culture results. Cultures should be obtained before starting antibiotic therapy to identify the causative organism accurately.
Correct Answer is A
Explanation
Choice A rationale
Increasing fluid intake helps flush out the barium contrast from the body to prevent constipation and promote bowel movements.
Choice B rationale
Over-the-counter antidiarrheal medications are not appropriate because barium can cause constipation, not diarrhea.
Choice C rationale
Barium contrast does not cause black, tarry stools. Instead, it causes stools to be white or light-colored.
Choice D rationale
Following a low-fiber diet is not recommended after a barium contrast study. High-fiber foods help facilitate bowel movements.
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