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 C
Explanation
Choice A rationale
Propranolol should not be increased if the apical heart rate is less than 60/min, as it can cause bradycardia.
Choice B rationale
Propranolol does not cause increased hair growth. This is not a side effect of the medication.
Choice C rationale
Withholding propranolol if the systolic blood pressure is less than 90 mm Hg is important because the medication can lower blood pressure further, leading to hypotension.
Choice D rationale
Propranolol should not be administered with an antacid as it can decrease the absorption and effectiveness of the medication.
Correct Answer is B
Explanation
Choice A rationale
Helicobacter pylori infection is associated with gastrointestinal conditions like peptic ulcers and gastritis, not with inner ear inflammation.
Choice B rationale
Viral respiratory infections can spread to the middle ear through the Eustachian tube, potentially leading to inflammation and infection of the inner ear (otitis media).
Choice C rationale
A tumor pressing on the pituitary gland can cause hormonal imbalances but is not directly related to inner ear inflammation.
Choice D rationale
Ampicillin, an antibiotic, is used to treat bacterial infections but does not inherently increase the risk of inner ear inflammation.
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