A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?
Vomiting Hypoglycemia
Hypertension
Altered mental status
Elevated WBC’s count
The Correct Answer is C
A. Vomiting is not a specific manifestation of sepsis.
B. Hypertension is not a typical finding in sepsis; hypotension is more common.
C. Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D. While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Continuous passive motion (CPM) machines are typically used after joint surgeries, not thoracic surgeries.
B. A chest tube is often used postoperatively after a lobectomy to drain excess air, fluid, or blood from the pleural space.
C. A three-way urethral catheter may be used for urinary drainage, but it is not specific to thoracic surgery.
D. Electroencephalography (EEG) monitoring wires are used for monitoring brain activity and are not typically used in the postoperative care of a client following a lobectomy.
Correct Answer is D
Explanation
A. The use of an incentive spirometer is more relevant for preventing respiratory complications, not related to the client's low WBC count.
B. Negative-pressure airflow rooms are typically used for clients with airborne infections, not those with low WBC counts.
C. Cooked fruits may be advisable to reduce the risk of bacterial contamination in immunosuppressed clients, but it does not directly address the low WBC count.
D. Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is crucial as it may indicate an infection, and prompt intervention is needed in immunosuppressed clients.
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