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 ["1000"]
Explanation
Step 1: Calculate the total caloric reduction needed per week to lose 0.9 kg (2 lb). 2 lb × 3,500 calories/lb = 7,000 calories.
Step 2: Divide the total weekly caloric reduction by the number of days in a week. 7,000 calories ÷ 7 days = 1,000 calories/day.
Final answer: 1,000.
Correct Answer is A
Explanation
Choice A rationale
Hand hygiene is critical for preventing the spread of MRSA. Washing hands removes any bacteria that may have been picked up during contact with the infected client or surfaces in the room. Proper handwashing technique includes using soap and water or an alcohol-based hand sanitizer for at least 20 seconds.
Choice B rationale
Reusing unsoiled gloves is not recommended because MRSA can persist on surfaces and gloves for prolonged periods. Changing gloves each time entering the room ensures any contamination is not transferred to different areas or patients.
Choice C rationale
Wearing a gown protects the caregiver’s clothing from contamination when assisting with activities like bathing. Gowns act as a barrier to prevent MRSA from contacting the caregiver's skin or clothes and being carried outside the patient’s room.
Choice D rationale
Taking the client outside the room increases the risk of spreading MRSA to others. While a mask may protect against respiratory droplets, it does not prevent the transmission of MRSA via contact with contaminated surfaces or the patient’s skin.
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