The nurse assesses a client with sepsis.
Which evaluations should the nurse include in a focused assessment? Select all that apply.
Breath sounds.
Urine output.
Capillary blood glucose.
Skin temperature.
Date of last bowel movement.
Correct Answer : A,B,D
Sepsis requires a focused assessment of systemic perfusion and the inflammatory response. Knowledge of the Sequential Organ Failure Assessment criteria is necessary. The nurse must prioritize assessments that reflect respiratory function, renal perfusion, and peripheral microvascular status to detect early deterioration.
Choice A rationale
Sepsis often leads to increased capillary permeability and acute lung injury. Assessing breath sounds allows the nurse to detect adventitious sounds like crackles, which may indicate the development of pulmonary edema or progressing respiratory distress or infection.
Choice B rationale
Urine output is a primary indicator of organ perfusion. In sepsis, decreased output less than 0.5 mL per kg per hr suggests inadequate renal blood flow or acute kidney injury resulting from systemic hypotension and inflammatory damage.
Choice C rationale
While glucose levels can fluctuate during the stress response of sepsis, it is not a primary component of a focused sepsis assessment compared to hemodynamic markers. Hyperglycemia is common but does not specifically define the septic state.
Choice D rationale
Skin temperature and capillary refill provide information about peripheral perfusion. In early sepsis, skin may be warm due to vasodilation, while late sepsis often presents with cool, clammy skin as the body shunts blood to organs.
Choice E rationale
The date of the last bowel movement is a part of a general gastrointestinal assessment but is not a priority in a focused sepsis evaluation. It does not provide immediate data regarding systemic inflammatory response or perfusion..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Circumferential burns to the chest create an inelastic band of eschar. Knowledge of respiratory mechanics and surgical emergencies is needed to identify when tissue tension prevents lung expansion, necessitating an immediate procedure to restore adequate ventilation and oxygenation.
Choice A rationale
Chest tube insertion is utilized to drain air or fluid from the pleural space. While it helps with lung expansion in a pneumothorax, it does not treat the external constriction caused by burnt, leathery tissue on the chest.
Choice B rationale
Cricothyrotomy is an emergency airway procedure used when intubation is impossible. Since the client is already intubated, the issue is not airway patency but rather the physical inability of the chest wall to expand against the eschar.
Choice C rationale
Thoracentesis is the removal of fluid from the pleural cavity via needle aspiration. This does not address the restrictive external pressure caused by circumferential, full-thickness burns that are inhibiting the mechanical rise and fall of the thorax.
Choice D rationale
An escharotomy involves making incisions through the burnt tissue to relieve pressure. This procedure allows the chest wall to expand, restoring adequate ventilation when circumferential eschar acts like a tourniquet around the patient's torso and lungs..
Correct Answer is C
Explanation
Post-stroke rehabilitation necessitates the application of interdisciplinary care coordination principles. Knowledge of the specific scopes of practice for various therapists is required to identify which professional specializes in adapting the environment and teaching techniques for performing essential daily self-care tasks.
Choice A rationale
Physical therapists primarily focus on gross motor skills, such as gait training, balance, and lower extremity strength. While they assist with mobility, they do not specialize in the fine motor tasks or adaptive equipment used for daily self-care activities.
Choice B rationale
Case managers focus on the coordination of care, insurance authorization, and discharge planning. They facilitate the transition between care levels but do not provide the direct clinical therapy needed to improve a client's performance of daily tasks.
Choice C rationale
Occupational therapists specialize in helping clients regain independence with activities of daily living, such as dressing, bathing, and eating. They utilize task modification and adaptive devices to address the fine motor and cognitive deficits following a stroke.
Choice D rationale
Social workers address the psychosocial needs, financial resources, and emotional support systems of the client and family. While they assist with the broader aspects of recovery, they do not have the clinical training to improve physical self-care abilities..
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