The critical care nurse cares for a client diagnosed with septic shock. Which observation MOST concerns the nurse?

Serum glucose 120 mg/dL.

White cell count 15,000/mm³.

Skin is warm, dry, and flushed.

Bleeding noted around venipuncture site.

Answer and Explanation

The Correct Answer is D

Choice A reason: Serum glucose of 120 mg/dL is normal and not concerning in septic shock, where coagulopathy is critical. Bleeding at the venipuncture site suggests DIC, making this incorrect, as it’s less urgent than the nurse’s priority of addressing potential bleeding complications.

Choice B reason: A white cell count of 15,000/mm³ is expected in septic shock due to infection. Bleeding indicates coagulopathy, a severe complication, making this incorrect, as it’s a typical finding compared to the nurse’s concern for life-threatening bleeding in the client.

Choice C reason: Warm, dry, flushed skin is common in early septic shock’s hyperdynamic phase. Bleeding suggests disseminated intravascular coagulation, making this incorrect, as it’s less concerning than the nurse’s priority of addressing a potential coagulopathy in the septic shock client.

Choice D reason: Bleeding around the venipuncture site in septic shock suggests disseminated intravascular coagulation, a life-threatening complication. This aligns with critical care priorities, making it the correct observation most concerning to the nurse, requiring immediate intervention to address coagulopathy.

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Correct Answer is D

Explanation

Choice A reason: Antibiotics treat infection, but fever, tenderness, and rising creatinine suggest rejection, not infection. Immunosuppression addresses rejection, making this incorrect, as it’s less likely than the nurse’s anticipation of therapy to manage transplant rejection in the client.

Choice B reason: Peritoneal dialysis is used for kidney failure, not acute transplant rejection, which causes fever and creatinine rise. Immunosuppression is needed, making this incorrect, as it’s irrelevant to the nurse’s expected treatment for the client’s post-transplant symptoms.

Choice C reason: Removing the kidney is a last resort, not the first response to rejection signs like fever and tenderness. Increased immunosuppression is standard, making this incorrect, as it’s premature compared to the nurse’s anticipation of rejection management.

Choice D reason: Increased immunosuppression treats acute transplant rejection, indicated by fever, tenderness, rising creatinine, and kidney enlargement. This aligns with post-transplant care, making it the correct treatment the nurse would anticipate for the client’s symptoms one week after transplantation.

A. Assisting the patient with ambulation and evaluating pain level. B. Administering prescribed medication and monitoring for side effects. C. Performing a full head-to-toe assessment and identifying any complications. D. Educating the patient on discharge instructions for post-operative care.

Correct Answer is B

Explanation

Choice A reason: Evaluating pain level requires RN judgment, though assisting with ambulation is within the LPN’s scope. Medication administration is fully delegable, making this incorrect, as it includes an assessment task beyond the LPN’s role in post-operative care.

Choice B reason: Administering prescribed medication and monitoring for side effects is within the LPN’s scope, ensuring safe delegation. This aligns with post-operative care protocols, making it the correct task the nurse can safely delegate to the LPN for the knee replacement patient.

Choice C reason: A full head-to-toe assessment and identifying complications require RN expertise, exceeding LPN scope. Medication administration is appropriate, making this incorrect, as it’s an improper delegation for the nurse to assign to the LPN post-surgery.

Choice D reason: Educating on discharge instructions involves teaching and evaluation, an RN responsibility. Administering medication is within LPN scope, making this incorrect, as it’s not a safe task for the nurse to delegate to the LPN for the patient.

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The critical care nurse cares for a client diagnosed with septic shock. Which observation MOST concerns the nurse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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