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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Dyskinesias, which are involuntary, erratic, writhing movements of the face, arms, legs, or trunk, are common side effects of long-term use of levodopa and carbidopa, especially after many years of therapy.
Choice B reason: Dyspnea, or difficulty breathing, is not commonly associated as a side effect of levodopa and carbidopa.
Choice C reason: Hypertension is not typically a side effect of levodopa and carbidopa; these medications can sometimes cause low blood pressure, particularly upon standing.
Choice D reason: Cold intolerance is not a recognized side effect of levodopa and carbidopa.
Correct Answer is C
Explanation
Choice A reason: Less constipation is not a direct indicator of effective PTU therapy, as constipation can be associated with hypothyroidism, and PTU is used to treat hyperthyroidism.
Choice B reason: Weight loss is expected in hyperthyroidism, and PTU is used to reduce thyroid hormone levels, not to promote weight loss.
Choice C reason: A reduction in facial puffiness can indicate that the PTU is effectively reducing thyroid hormone levels, as puffiness can be associated with hyperthyroidism.
Choice D reason: Improvement in vision is not a typical outcome of PTU therapy and does not directly indicate its effectiveness.
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