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: Pulse pressure is calculated as systolic (90) minus diastolic (72), equaling 18 mm Hg, not 40. This is incorrect, as it overestimates the pulse pressure, unlike the nurse’s accurate calculation based on the patient’s blood pressure readings.

Choice B reason: A pulse pressure of 25 mm Hg doesn’t match the calculation of 90 minus 72, which is 18 mm Hg. This is incorrect, as it’s inaccurate compared to the nurse’s correct determination of the patient’s pulse pressure from the given values.

Choice C reason: Pulse pressure is systolic (90 mm Hg) minus diastolic (72 mm Hg), equaling 18 mm Hg. This aligns with cardiovascular assessment, making it the correct value the nurse would calculate for the patient’s blood pressure of 90/72 mm Hg.

Choice D reason: A pulse pressure of 12 mm Hg is incorrect, as 90 minus 72 equals 18 mm Hg. This underestimates the value, making it incorrect compared to the nurse’s accurate calculation of the patient’s pulse pressure based on the blood pressure.

A. Asking the LPN to administer an intramuscular injection to a patient. B. Asking the LPN to assess a post-operative patient’s wound for signs of infection. C. Asking the MA to complete a follow-up call with a patient about test results. D. Asking the MA to insert a nasogastric tube in a patient who requires nutritional support.

Correct Answer is A

Explanation

Choice A reason: Administering an intramuscular injection is within the LPN’s scope of practice, ensuring safe delegation. This aligns with nursing delegation guidelines, making it the correct example of appropriate task assignment for the nurse to delegate to the LPN on a busy unit.

Choice B reason: Assessing a wound for infection requires RN judgment, exceeding the LPN’s scope. Administering an injection is appropriate, making this incorrect, as it’s an improper delegation compared to the nurse’s choice of a task within the LPN’s role.

Choice C reason: MAs cannot discuss test results, as this requires clinical judgment beyond their scope. LPN injection administration is correct, making this incorrect, as it’s an inappropriate task for the MA compared to the nurse’s proper delegation choice.

Choice D reason: Inserting a nasogastric tube is an RN task, not within the MA’s scope. LPN injection administration is appropriate, making this incorrect, as it’s unsafe delegation compared to the nurse’s selection of a task suitable for the LPN.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient’s blood pressure is 90/72 mm Hg. What is the patient’s pulse pressure?

Correct Answer is C

Explanation

You are working on a busy unit and need to delegate tasks to the LPN and M

Correct Answer is A

Explanation

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