A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)
A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min.
A client who has a heart rate of 132/min and a respiratory rate of 30/min.
A client who has a decrease in level of consciousness and a heart rate greater than 130/min.
A client who has bradypnea and a white blood cell (WBC) count of 10,000/mm³ (normal range: 5,000 to 10,000/mm³).
A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min.
Correct Answer : B,C
Choice A reason:
A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.
Choice B reason:
A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.
Choice C reason:
A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.
Choice D reason:
Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm³ is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.
Choice E reason:
A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Testicular torsion is a condition where the spermatic cord becomes twisted, cutting off the blood supply to the testicle. It is not a typical complication following a prostatectomy. Testicular torsion is generally an acute condition that affects younger males and is unrelated to prostate surgery.
Choice B reason:
Erectile dysfunction (ED) is a common complication after prostatectomy. The surgery can damage the nerves and blood vessels that control erections, leading to ED. While nerve-sparing techniques aim to reduce this risk, some degree of erectile dysfunction is still possible after the procedure.
Choice C reason:
Cystitis, which is inflammation of the bladder, can occur after a prostatectomy due to the use of a catheter or as a result of the surgery itself. However, it is not as common or as significant a long-term complication as erectile dysfunction.
Choice D reason:
Paralytic ileus, a temporary cessation of bowel movements, can occur after any abdominal surgery due to the manipulation of the intestines or as a side effect of anesthesia. While it can be a complication of prostatectomy, it is typically resolved within a few days to weeks after surgery.
Correct Answer is A
Explanation
Choice A: Monitor the client for hypoglycemia
When a nurse administers an incorrect insulin dose, the immediate concern is the risk of hypoglycemia, especially since the insulin dose given was for a higher blood glucose level than the actual reading. Hypoglycemia can occur when blood glucose levels drop below 70 mg/dL. Symptoms of hypoglycemia include shakiness, sweating, confusion, and in severe cases, loss of consciousness. Monitoring the client for hypoglycemia allows the nurse to detect and treat it promptly, ensuring the client’s safety.
Choice B: Complete an incident report
While completing an incident report is important for documenting the medication error and preventing future occurrences, it is not the immediate priority. The nurse’s first responsibility is to ensure the client’s safety by addressing the potential hypoglycemia. Once the client’s condition is stable, the nurse can then complete the incident report.
Choice C: Give the client 15 to 20 g of carbohydrate
Administering 15 to 20 grams of carbohydrate is a treatment for hypoglycemia. However, this action should only be taken if the client is actually experiencing hypoglycemia. The nurse should first monitor the client’s blood glucose levels to confirm hypoglycemia before administering carbohydrates.
Choice D: Notify the nurse manager
Notifying the nurse manager is important for accountability and to ensure that appropriate follow-up actions are taken. However, it is not the immediate priority. The nurse should first monitor the client for hypoglycemia and address any immediate health concerns before notifying the nurse manager.
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