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 e to the client's
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale:
• Antibiotic: Administering an antibiotic addresses the underlying infection, which is likely causing the fever, low blood pressure, and altered mental status. Prompt antibiotic treatment reduces the risk of progression to septic shock. Early intervention improves patient outcomes in suspected sepsis.
• Antipyretic: An antipyretic helps reduce fever but does not treat the underlying infection. Lowering the temperature alone would not address the systemic inflammatory response seen in sepsis. This option does not prevent clinical deterioration.
• Anti-anxiety medication: An anti-anxiety medication may temporarily calm the patient but can worsen confusion and mask signs of deterioration. It does not treat the infection or improve hemodynamic status. This is inappropriate in suspected sepsis.
• Suspected surgical site infection and sepsis: The inflamed, draining surgical wound, fever, hypotension, and high WBC strongly indicate a developing infection. Mental status changes are also typical in sepsis. This makes infection the most urgent concern requiring antibiotic therapy.
• Elevated temperature and heart rate: While these signs are concerning, they are common with many conditions and not specific to sepsis. They are part of the clinical picture but not the driving reason for immediate antibiotic treatment.
• History of Parkinson’s disease and confusion: The confusion may partly relate to Parkinson’s or sensory impairment, but acute mental status changes with fever and hypotension suggest sepsis. Parkinson’s is chronic and not the immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Eat foods high in vitamin B: Although B-vitamin deficiencies can contribute to stomatitis, eating foods high in vitamin B may not immediately relieve symptoms. Nutritional support is important long-term, but bland food recommendations provide immediate comfort.
B. Consume soft, bland foods: Soft, bland foods reduce mechanical and chemical irritation to the oral mucosa, promoting healing and reducing discomfort. These are ideal dietary choices for clients with stomatitis.
C. Rinse the mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can worsen irritation and dryness of the oral mucosa, aggravating stomatitis symptoms. Alcohol-free rinses or saline solutions are better alternatives.
D. Use lemon glycerin swabs: Lemon glycerin swabs can cause further drying and irritation of the mucosa. They are not recommended for clients with stomatitis, as they may intensify pain and inflammation.
Correct Answer is A
Explanation
Rationale:
A. "Prednisone can cause blood glucose levels to increase”: Prednisone is a corticosteroid that can increase blood glucose by promoting gluconeogenesis and reducing cellular glucose uptake. Monitoring glucose levels is important, especially in clients receiving moderate to high doses.
B. "Albuterol treatments can cause blood glucose levels to decrease.": Albuterol is more likely to cause mild hyperglycemia due to its beta-agonist activity, which can stimulate glycogenolysis. It does not typically cause a drop in blood glucose levels.
C. "Having COPD causes blood glucose levels to fluctuate.": COPD alone does not directly cause blood glucose fluctuations. However, glucose changes are more commonly influenced by treatments like corticosteroids rather than the disease itself.
D. "Older adults are at risk for developing type 1 diabetes mellitus.”: Type 1 diabetes is typically diagnosed in children and young adults due to autoimmune beta-cell destruction. Older adults are more at risk for type 2 diabetes, not type 1.
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