A nurse is assisting with the care of a preschooler who sustained a major burn injury 5 days ago. Which of the following findings should the nurse identify as a manifestation of sepsis?

Polyuria

Disorientation

Hyperactive bowel sounds

Hypoglycemia

Answer and Explanation

The Correct Answer is B

A. Polyuria is not typically associated with sepsis; it may be seen in other conditions such as diabetes. In sepsis, urine output is often decreased due to impaired kidney function and shock.
B. Disorientation is a sign of sepsis, indicating that the infection may have spread to the bloodstream and is affecting the central nervous system. Altered mental status is a critical indicator of severe infection.
C. Hyperactive bowel sounds are not associated with sepsis. In sepsis, bowel sounds may actually be decreased due to decreased perfusion to the gastrointestinal tract.
D. Hypoglycemia can occur in sepsis, but it is not as specific an indicator as disorientation. Monitoring blood glucose levels is important, but disorientation provides a clearer sign of systemic infection.

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Correct Answer is C

Explanation

A. BUN level of 12 mg/dL is within normal range and does not indicate infection.
B. Urine specific gravity of 1.014 is within normal range and does not indicate infection.
C. A WBC count of 17,500/µL is elevated and indicates a possible infection, which should be reported immediately.
D. Urine osmolality of 500 mOsm/kg is within normal range and does not indicate infection.

A. Instruct the parent to give the child an oatmeal bath twice daily. B. Flush the area with cold, running water. C. Administer an oral corticosteroid. D. Apply calamine lotion to the affected area.

Correct Answer is B

Explanation

A. An oatmeal bath can soothe the skin but is not the immediate first step.
B. Flushing the area with cold, running water helps remove the plant oils that cause the reaction and is the first step in managing poison ivy exposure.
C. Administering an oral corticosteroid may be necessary for severe reactions but is not the first action to take.
D. Calamine lotion can help with itching but should be applied after washing off the plant oils.

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A nurse is assisting with the care of a preschooler who sustained a major burn injury 5 days ago. Which of the following findings should the nurse identify as a manifestation of sepsis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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