The nurse is assessing a client admitted for treatment of pneumonia and possible sepsis. Which information is most important for the nurse to report?

Serum lactate level 3.9 mmol/L (normal range: 0.5-2 mmol/L)

Vital signs: Temperature 100°F, Heart rate 88 bpm, Respiratory rate 22 breaths/min, Blood pressure 124/72 mmHg

Pulse oximetry 96% on oxygen at 2 L/min via nasal cannula

Breath sounds with rhonchi bilaterally

Answer and Explanation

The Correct Answer is A

Choice A reason: The serum lactate level of 3.9 mmol/L is significantly higher than the normal range of 0.5-2 mmol/L. This is a critical value to report as it indicates a high likelihood of sepsis, which is a life-threatening condition requiring immediate intervention. Elevated lactate levels suggest that the tissues are not adequately oxygenated, a state known as tissue hypoxia, which is a hallmark of sepsis.

Choice B reason: While the vital signs show a slight fever (100°F), the heart rate, respiratory rate, and blood pressure are within normal limits for an adult and do not indicate an immediate life-threatening condition.

Choice C reason: A pulse oximetry reading of 96% on supplemental oxygen is within the acceptable range, indicating adequate oxygen saturation and not a direct sign of sepsis.

Choice D reason: The presence of rhonchi bilaterally suggests airway obstruction due to mucus, which can be associated with pneumonia. However, this finding alone does not carry the same immediate risk of morbidity and mortality as an elevated lactate level indicative of sepsis.

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Correct Answer is A

Explanation

Choice A reason: A thyroidectomy, which is the surgical removal of the thyroid gland, directly leads to hypothyroidism because the body can no longer produce thyroid hormones. This client is at the greatest risk of developing hypothyroidism.

Choice B reason: While exposure to certain chemicals in pesticides can be a risk factor for thyroid dysfunction, it does not pose as immediate a risk as the removal of the thyroid gland itself.

Choice C reason: Thyroid nodules can be associated with thyroid dysfunction, but not all nodules result in hypothyroidism, and many are benign and asymptomatic.

Choice D reason: Vomiting secondary to influenza is not directly related to the development of hypothyroidism.

A. Assess temperature. B. Monitor urine output. C. Administer antibiotics. D. Evaluate current CBC (Complete Blood Count).

Correct Answer is C

Explanation

Choice A reason: While assessing temperature is important for monitoring infection, it is not the immediate priority in the treatment of UTI and sepsis.

Choice B reason: Monitoring urine output is crucial for a UTI but does not address the systemic infection that sepsis represents.

Choice C reason: Administering antibiotics is the most critical intervention for a client with sepsis due to a UTI, as it directly addresses the underlying infection and can be life-saving.

Choice D reason: Evaluating the current CBC is important for understanding the client's baseline and response to infection but is secondary to the administration of antibiotics.

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The nurse is assessing a client admitted for treatment of pneumonia and possible sepsis. Which information is most important for the nurse to report?

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Naxlex Comprehensive Predictor Exams

The nurse practitioner is assessing clients for their risk of developing hypothyroidism. Which of these clients would the nurse consider at greatest risk?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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