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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
While pulmonary function studies are an important part of the preoperative assessment and postoperative follow-up for lung cancer patients, they are not typically something a patient would be immediately prepared for post-lobectomy. These studies are usually scheduled for a later date to assess the impact of the surgery on lung function.
Choice B reason:
A sternal incision is not commonly associated with a lobectomy, which involves an incision in the chest wall, not the sternum. Sternal incisions are more often related to procedures that require access to the heart or the central chest area, such as open-heart surgery.
Choice C reason:
Moderate pain is expected after any major surgical procedure, including a lobectomy. However, pain management is a standard part of postoperative care, and patients are typically informed about pain control measures rather than being prepared to expect pain as a postoperative event.
Choice D reason:
The placement of a chest tube is a standard part of care following a lobectomy. The chest tube allows for drainage of fluid and air from the pleural space, ensuring proper lung expansion and preventing complications such as pneumothorax. Patients should be educated about the chest tube's purpose, care, and the sensations they may experience while the tube is in place.
Correct Answer is C
Explanation
Choice A reason:
While metabolic syndrome is associated with several health issues, it is not a direct risk factor for hyperthyroidism. Metabolic syndrome typically includes conditions like insulin resistance, hypertension, and dyslipidemia, which are more closely related to diabetes and cardiovascular diseases rather than thyroid function.
Choice B reason:
An iodine deficiency is commonly associated with hypothyroidism, not hyperthyroidism. Iodine is essential for the production of thyroid hormones, and a lack of it can lead to decreased hormone production and an underactive thyroid.
Choice C reason:
Graves' disease is the most common cause of hyperthyroidism. It is an autoimmune disorder where the immune system mistakenly attacks the thyroid gland, causing it to produce too much thyroid hormone. A 35-year-old male with Graves' disease would indeed be at high risk for hyperthyroidism.
Choice D reason:
While a family history of autoimmune disorders can increase the risk of developing autoimmune-related hyperthyroidism, it is not as direct a risk factor as having Graves' disease itself. Autoimmune disorders can have a genetic component, but having a family history does not guarantee the development of hyperthyroidism.
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