The nurse continues to assist in the care of the client.
Complete the following sentence by using the lists of options.
The nurse should first ensure administration of the client's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
The client has a surgical site infection evidenced by purulent drainage, fever, hypotension, tachycardia, and elevated white blood cell count, all indicating systemic infection with risk for sepsis. In this situation, early antibiotic administration is the most time-sensitive intervention because it directly targets the underlying infectious cause. Prioritization is based on treating life-threatening etiologies before symptom control measures such as fever reduction or anxiety management.
Rationale for correct choices:
• Antibiotic: The priority medication is the antibiotic because the client is showing clear signs of severe postoperative wound infection progressing toward sepsis. Cefazolin is prescribed to treat the suspected bacterial infection, and early administration is critical to prevent further systemic deterioration. Delays in antibiotic therapy in septic or pre-septic states are associated with increased mortality and worsening hemodynamic instability. Therefore, ensuring prompt antibiotic delivery directly addresses the root cause of fever, hypotension, and delirium.
• WBC count: The elevated WBC count of 14,000/mm³ indicates an active systemic inflammatory response likely due to infection. This laboratory finding supports the need for urgent antibiotic therapy rather than focusing on symptom management alone. While temperature and restlessness are important clinical indicators, the WBC count confirms the presence of a bacterial process requiring antimicrobial treatment. It helps prioritize infection management as the primary clinical concern.
Rationale for incorrect choices:
• Antipyretic: Although acetaminophen may help reduce fever, it does not treat the underlying infection causing the client’s symptoms. Fever in this case is a protective response to infection and is secondary to the systemic inflammatory process. Administering antipyretics without addressing the infection could mask worsening clinical status. Therefore, it is not the priority over antibiotic therapy.
• Anti-anxiety medication: Alprazolam may reduce agitation, but it does not address the underlying cause of the client’s delirium, which is likely infection-related sepsis. Sedation in a hypotensive, infected older adult may worsen respiratory status and mask deterioration. Benzodiazepines can also exacerbate delirium in older adults, particularly in ICU settings. Thus, anti-anxiety medication is not the priority intervention.
• Restlessness: While restlessness is a significant behavioral manifestation of delirium, it is a symptom rather than the underlying cause. Treating agitation without addressing the infection may worsen outcomes and delay lifesaving therapy. The client’s confusion and hallucinations are most likely secondary to systemic infection and hypotension. Therefore, restlessness is not the priority compared to the need for immediate antibiotic therapy.
• Temperature: Temperature reflects the presence of fever, which is a symptom of infection but not the most reliable indicator for prioritizing treatment in this scenario. Although the client is febrile (39.1°C), fever alone does not quantify the severity or progression of infection as accurately as laboratory findings such as WBC trends. In sepsis management, rising WBC count and hemodynamic instability provide stronger evidence of systemic infection requiring immediate antibiotic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Postoperative clients require close monitoring for early signs of infection, especially within the first few days after surgery when surgical sites are most vulnerable. Infection can develop due to bacterial contamination, impaired tissue healing, or compromised immunity. Common indicators include systemic inflammatory responses such as fever, leukocytosis, and localized signs at the incision site. Nurses must differentiate normal postoperative changes from findings that suggest infection to ensure timely intervention.
Rationale:
A. A temperature of 37.2°C (99.0°F) is within normal or low-grade postoperative range and does not indicate infection. Mild temperature elevations can occur after surgery due to atelectasis or the inflammatory healing process. It is not a reliable indicator of infection on its own.
B. Increased urinary output is not associated with postoperative infection. In fact, infection or sepsis may initially present with decreased urine output due to poor perfusion. Increased output is more likely related to fluid administration or improved renal perfusion.
C. A pain rating of 4/10 is expected in a postoperative client and is not specific for infection. Postoperative pain typically decreases gradually with healing. Infection-related pain is often worsening, localized, and associated with other inflammatory signs rather than a moderate stable pain score.
D. An elevated WBC count is a key indicator of infection because it reflects the body’s immune response to invading pathogens. In a client who is 2 days post abdominal surgery, leukocytosis may suggest developing surgical site infection or intra-abdominal infection. In conditions involving postoperative monitoring such as Postoperative infection, elevated WBCs warrant further assessment and possible intervention.
Correct Answer is C
Explanation
Interprofessional care conferences for clients who have experienced a stroke focus on identifying functional deficits, rehabilitation needs, and safety risks that require coordinated management. Stroke can result in motor, sensory, and cognitive impairments that significantly affect independence in activities of daily living. Early identification of deficits such as impaired hand function helps guide referrals to rehabilitation specialists. The goal is to restore function, promote independence, and prevent complications.
Rationale:
A. Preferring a snack before bedtime is a normal personal preference and does not indicate a clinical problem requiring interprofessional intervention. This is related to routine dietary habits and can be managed by nursing staff without additional team involvement. It does not reflect functional decline or rehabilitation needs.
B. Requesting to perform ADLs later in the day reflects client preference and possible fatigue management, which is common after a stroke. While it may inform care planning, it does not indicate a new or significant impairment requiring escalation. This can be accommodated within nursing care routines.
C. Inability to grasp eating utensils indicates significant motor impairment affecting fine motor coordination and upper extremity function, commonly seen after a stroke. This deficit requires referral to rehabilitation services such as occupational therapy to improve self-care ability and adapt assistive devices. In clients with Stroke, this finding is critical for interdisciplinary intervention.
D. Need for reinforcement of medication teaching is expected after a stroke due to possible cognitive or memory deficits. While it requires ongoing nursing education, it does not represent a new functional impairment requiring interprofessional escalation. This can be addressed through routine nursing interventions.
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