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: Deep brain stimulation is known to help reduce tremors in Parkinson's disease, which is one of the main symptoms that can be debilitating.
Choice B reason: While deep brain stimulation may help with some non-motor symptoms, it is not primarily used to treat urinary retention.
Choice C reason: Deep brain stimulation does not slow the progression of Parkinson's disease; it is used to manage symptoms.
Choice D reason: Deep brain stimulation is not a treatment for preventing depression, although it may improve overall quality of life.
Correct Answer is B
Explanation
Choice A reason: A high-fat diet is not recommended for clients with chronic pancreatitis as it can exacerbate symptoms and lead to malabsorption issues.
Choice B reason: Checking blood glucose is important because chronic pancreatitis can affect the endocrine function of the pancreas, potentially leading to diabetes.
Choice C reason: While a semi-Fowler's position may be comfortable for some patients, it is not specifically an intervention for chronic pancreatitis.
Choice D reason: Assessing for hypotension is a general nursing intervention but not specific to the management of chronic pancreatitis.
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