An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postburn infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8°F (39.3°C., heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?

Provide bedside equipment for transmission and protective precautions.

Evaluate daily serum electrolytes and hydration status.

Culture sputum, urine, burn wound, and all intravenous access sites.

Implement central line-associated bloodstream infection (CLABSI) protocols.

Answer and Explanation

The Correct Answer is C

Choice A: Providing bedside equipment for transmission and protective precautions is not the first action that the nurse should implement, as this is a standard precaution that should be already in place for all clients in the critical care unit. This is a distractor choice.

Choice B: Evaluating daily serum electrolytes and hydration status is not the first action that the nurse should implement, as this is a routine assessment that can be done later after addressing the immediate problem of infection. This is another distractor choice.

Choice C: Culturing sputum, urine, burn wound, and all intravenous access sites is the first action that the nurse should implement, as this can help identify the source and type of infection, which can guide the appropriate antibiotic therapy and prevent further complications. Therefore, this is the correct choice.

Choice D: Implementing central line-associated bloodstream infection (CLABSI) protocols is not the first action that the nurse should implement, as this is a preventive measure that may not be applicable for this client who already has SIRS. This is another distractor choice.

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Correct Answer is A

Explanation

Choice B reason: Forcing oral fluids and providing frequent small meals are not the most important interventions for a client with alcohol withdrawal delirium. Although hydration and nutrition are important to prevent dehydration and electrolyte imbalance, they are not the priority in this case. The client may have difficulty swallowing, vomiting, or aspiration due to altered mental status.

Choice C reason: Confronting the client's denial of substance abuse is not an appropriate intervention for a client with alcohol withdrawal delirium. The client may not be able to comprehend or respond rationally to such confrontation due to impaired cognition and perception. The nurse should avoid arguing or challenging the client's beliefs and focus on providing safety and comfort.

Choice D reason: Encouraging attendance and group participation is not a feasible intervention for a client with alcohol withdrawal delirium. The client may not be able to participate in any social or educational activities due to severe withdrawal symptoms and delusions. The nurse should limit visitors and stimuli and provide one-to-one supervision and reassurance.

A. Consume foods with saturated fats. B. Walk 30 minutes per day. C. Use a salt substitute. D. Keep a food diary. E. Eat more canned vegetables. F. Include oatmeal for breakfast.

Correct Answer is ["A","E"]

Explanation

Choice A reason: Consuming foods with saturated fats can increase the level of low-density lipoprotein (LDL) cholesterol in the blood, which can contribute to plaque formation and narrowing of the coronary arteries.

Choice B reason: Walking 30 minutes per day can help lower blood pressure, improve blood circulation, and reduce the risk of heart attack and stroke.

Choice C reason: Using a salt substitute can help lower sodium intake, which can reduce fluid retention and lower blood pressure.

Choice D reason: Keeping a food diary can help the client monitor their calorie intake, portion size, and nutritional balance.

Choice E reason: Eating more canned vegetables can increase sodium intake, which can worsen fluid retention and blood pressure. Fresh or frozen vegetables are preferable.

Choice F reason: Including oatmeal for breakfast can provide soluble fiber, which can lower LDL cholesterol and prevent plaque formation in the coronary arteries.

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Naxlex Comprehensive Predictor Exams

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

Correct Answer is A

Explanation

Text 1:The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

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