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 C

Explanation

Choice A reason: Supplemental oxygen is unnecessary with a normal respiratory rate (16) and stable vitals. Maintaining the collar prevents spinal injury, making this incorrect, as it’s not indicated compared to the nurse’s priority of ensuring spinal stability in a client with a fall history.

Choice B reason: Morphine for pain is premature without confirming spinal stability, as it may mask symptoms. Keeping the collar in place is critical, making this incorrect, as it risks missing neurological changes in the nurse’s care of a potential spinal injury client.

Choice C reason: Keeping the hard collar in place until cleared by imaging prevents worsening of potential spinal injury after a trampoline fall. This aligns with trauma care protocols, making it the correct action for the nurse to take to ensure the client’s safety and stability.

Choice D reason: Methylprednisolone is used for confirmed spinal cord injury, not suspected cases without imaging. Maintaining the collar is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on spinal precautions in a client with numbness and tingling.

A. Eating leafy green vegetables with a glass of water. B. Eating apple slices with carrots. C. Eating a steak with mushrooms. D. Eating calf’s liver with a glass of orange juice.

Correct Answer is D

Explanation

Choice A reason: Leafy greens contain iron, but water doesn’t enhance absorption; vitamin C does. Calf’s liver with orange juice maximizes absorption, making this incorrect, as it lacks the vitamin C component the nurse should teach to improve iron uptake in anemia.

Choice B reason: Apples and carrots have minimal iron and no vitamin C to enhance absorption. Calf’s liver with orange juice is optimal, making this incorrect, as it doesn’t provide iron or absorption enhancers compared to the nurse’s teaching for iron deficiency anemia.

Choice C reason: Steak is iron-rich, but mushrooms don’t significantly enhance absorption like vitamin C. Orange juice with liver is better, making this incorrect, as it’s less effective than the nurse’s recommendation to pair iron with a vitamin C source for anemia.

Choice D reason: Calf’s liver is high in iron, and orange juice’s vitamin C enhances non-heme iron absorption. This aligns with nutritional education for iron deficiency anemia, making it the correct choice for the nurse to teach the client to improve iron absorption effectively.

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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 C

Explanation

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?

Correct Answer is D

Explanation

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?

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