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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Free Nursing Study Resources

Correct Answer is ["B","C","E","F"]

Explanation

Choice B is correct because weight management is an important factor in preventing and controlling hypertension. Taking daily walks for thirty minutes can help reduce weight and lower blood pressure.

Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Sodium intake is associated with increased blood pressure and should be limited to less than 2,300 mg per day.

Choice E is correct because sodium intake can be regulated by rinsing canned foods in water. Canned foods often contain high amounts of sodium as a preservative and rinsing them can remove some of the excess sodium.

Choice F is correct because uncontrolled hypertension can lead to renal damage. Hypertension can cause damage to the blood vessels and impair the function of the kidneys, leading to chronic kidney disease or failure.

Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol intake should be limited to no more than one drink per day for women and two drinks per day for men.

Choice D is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner.

A. Check for a distended bladder. B. Review the hemoglobin to determine hemorrhage. C. Massage the uterus to decrease atony. D. Increase intravenous infusion.

Correct Answer is A

Explanation

Choice B reason: Reviewing the hemoglobin to determine hemorrhage is an important action, but not the first one. The nurse should first identify and correct the cause of bleeding, such as bladder distension or uterine atony, before checking for blood loss and anemia.

Choice C reason: Massaging the uterus to decrease atony is not indicated in this case, because the uterus is already firm. Massaging a firm uterus can cause overstimulation and pain.

Choice D reason: Increasing intravenous infusion is not the first action, because it may worsen bleeding by increasing blood pressure and diluting clotting factors. The nurse should first assess and manage bleeding before administering fluids or blood products as prescribed.

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Naxlex Comprehensive Predictor Exams

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply)

Correct Answer is ["B","C","E","F"]

Explanation

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm and three fingerbreadths above the umbilicus. What action should the nurse implement first?

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.)

A preschool-aged child who is being tested for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the clearest indication to the nurse that the child is experiencing a reaction to toxins that are created by Streptococcal bacteria.

The healthcare provider prescribes and IV solution of regular insulin (Humulin-R) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hour?

Which statement should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?