Patient Data

Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Temperature 98.8° F (37.1° C)

Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic

Serum blood glucose 185 mg/dL (10.2 mmol/L)

White blood cell count 11.2 x 103/µL (11.2 x 109/L)

Capillary refill greater than 3 seconds bilateral lower extremities

Bilateral lower extremities skin warm, dry, and pink

Answer and Explanation

Correct Answer : A,D,F

Rationale:
A. Temperature 98.8° F (37.1° C): A normal body temperature indicates resolution of the infection and a positive response to antibiotic therapy for cellulitis. Fever reduction is a key indicator of therapeutic effectiveness.

B. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: While pain is low, the description of neuropathic pain unrelated to cellulitis does not reflect improvement in the infection itself, so it is not a primary indicator of therapeutic response.

C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although improved from the initial hyperglycemia, this level is still above the normal range. It does not directly indicate resolution of cellulitis or therapeutic effectiveness of antibiotic therapy.

D. White blood cell count 11.2 x 103/µL (11.2 x 10⁹/L): The decrease toward normal limits from an elevated WBC demonstrates a positive hematologic response to treatment and reduced systemic inflammation caused by the infection.

E. Capillary refill greater than 3 seconds bilateral lower extremities: Prolonged capillary refill indicates peripheral perfusion deficits. Persistent abnormal refill is not a sign of therapeutic response and may reflect ongoing vascular compromise.

F. Bilateral lower extremities skin warm, dry, and pink: Improvement in skin color, warmth, and absence of edema or erythema reflects resolution of cellulitis and effective local tissue recovery, consistent with therapeutic response.

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Correct Answer is ["C","D"]

Explanation

A. Fever greater than 101.5° F (38.6° C): Fever may indicate infection, such as meningitis or shunt infection, but it is not a primary sign of increased intracranial pressure (ICP) in infants.

B. Decreased urinary output: Oliguria is not a typical early sign of increased ICP. While it can occur with severe systemic compromise, it is not a direct indicator of ICP changes.

C. Sunsetting eyes: The “sunsetting” sign, where the eyes appear driven downward with the sclera visible above the iris, is a classic indicator of increased ICP in infants due to hydrocephalus and should be closely monitored.

D. Bulging anterior fontanel: A bulging anterior fontanel reflects increased pressure within the cranial vault and is a key early sign of increased ICP in infants.

E. Jugular venous distension: Jugular venous distension is more indicative of cardiac or fluid overload issues rather than increased ICP in infants.

A. Intubation tray. B. Chest tube insertion tray. C. Crash cart. D. Ventilator.

Correct Answer is B

Explanation

A. Intubation tray: An intubation tray is necessary if the client experiences airway compromise or respiratory failure, but it does not directly address complications from an ineffective thoracentesis, such as persistent pneumothorax or pleural effusion.

B. Chest tube insertion tray: If the thoracentesis is ineffective and the pleural space continues to fill or air accumulates, a chest tube may be required to drain fluid or air and re-expand the lung. Having a chest tube tray ready ensures rapid intervention for these potential complications.

C. Crash cart: A crash cart is essential for emergencies involving cardiac or respiratory arrest, but it is not the first-line equipment for an ineffective thoracentesis unless the client acutely decompensates.

D. Ventilator: Mechanical ventilation may be required for severe respiratory failure, but it is not an immediate bedside intervention for an unsuccessful thoracentesis. The priority is to remove fluid or air from the pleural space.

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Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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Patient Data

Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.