The nurse is caring for a client who has an infection that has spread throughout the body. Vital signs are temperature 101°F (38.3°C), heart rate 94 beats per minutes, respiratory rate 22 breaths per minute, systolic blood pressure 87 mmHg, and mean arterial pressure (MAP) 66 mmHg. The client's white blood cell count is 14,000/mm3 (14 x 10 ⁹/L) and decreased urinary output to less than 0.5 mL/kg/hr. These signs are indicative of which condition?

Reference range:
White blood cells (WBC) [5,000 to 10,000/mm3 (5 to 10x 10 ⁹/L

Organ failure (severe sepsis).

Systemic infection (early sepsis).

Multiple organ dysfunction syndrome (MODS).

Systemic inflammatory response syndrome (SIRS).

Answer and Explanation

The Correct Answer is A

Septic shock and severe sepsis involve a dysregulated host response to infection resulting in life-threatening organ dysfunction. This pathological state triggers capillary leak, systemic vasodilation, and microvascular coagulation. Clinical indicators include a serum lactate >2 mmol/L and hypotension requiring vasopressors.

Rationale:

A. The presence of hypotension and oliguria signifies organ dysfunction resulting from inadequate tissue perfusion. A systolic blood pressure <90 mmHg and MAP <70 mmHg indicate a transition from simple infection to severe sepsis. These findings demonstrate that the systemic inflammatory response has compromised vital organ systems.

B. Early sepsis typically presents with fever and tachycardia but lacks signs of end-organ damage or significant hypotension. While the elevated WBC and heart rate are present, the decreased urinary output specifically indicates that the condition has progressed beyond a simple systemic infection.

C. This syndrome represents the final stage where two or more organ systems fail and homeostasis cannot be maintained without intervention. While this client shows signs of early failure, they do not yet meet the criteria for multiple organ failure involving respiratory, hepatic, or hematologic collapse.

D. This syndrome is a clinical response to a variety of severe insults, including trauma or burns, characterized by systemic inflammation. While the client meets the criteria for this response, the presence of a confirmed infection and organ dysfunction makes severe sepsis a more specific and accurate clinical diagnosis.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","D"]

Explanation

Brief introduction:

Asthma involves chronic airway inflammation and hyperresponsiveness leading to reversible bronchoconstriction. During an acute exacerbation, triggers like exercise or viral infections cause smooth muscle contraction, mucosal edema, and mucus plug formation. This increases airway resistance and reduces ventilation-perfusion ratios, causing hypoxemia and tachypnea.

Rationale:

A. Administering a short-acting beta-2 agonist like albuterol is a priority to reverse acute bronchospasm. This medication rapidly stimulates beta receptors in the lungs to induce bronchial relaxation. Opening the airways facilitates gas exchange and reduces the work of breathing during a severe asthma attack.

B. Providing a regular diet tray is a non-urgent intervention and should be delayed. The client is currently experiencing respiratory distress and has difficulty speaking, making oral intake a secondary concern. Focusing on nutritional support before stabilizing the patient’s airway and oxygenation status is inappropriate clinical practice.

C. Pulmonary function tests are diagnostic tools used to assess lung capacity but are not for acute management. Attempting these tests while a patient is actively wheezing and pale could worsen respiratory fatigue. Initial treatment must focus on immediate physiological stabilization rather than gathering baseline long-term diagnostic data.

D. Oxygen therapy must be initiated immediately to treat cellular hypoxia indicated by an oxygen saturation of 91%. Restoring oxygen levels protects vital organs from ischemic damage while pharmacological agents work to open the constricted airways. Maintenance of saturation >94% ensures adequate peripheral tissue oxygenation during respiratory distress.

E. While monitoring vital signs is important, it is an assessment rather than a stabilizing intervention. In an emergency, the nurse should prioritize actions that directly treat the underlying pathology of hypoxia and bronchoconstriction. Life-saving treatments like albuterol and oxygen must precede the routine documentation of circulatory and respiratory rates.

A. Encourage active range of motion to limit stiffness. B. Avoid the consumption of wine, beer, and coffee. C. Substitute natural fruit juices for carbonated drinks. D. Use electric heating pad when pain is at its wors

Correct Answer is B

Explanation

Gouty arthritis is a metabolic disorder characterized by the accumulation of urate crystals in the joints, most commonly the first metatarsophalangeal joint or the ankle. This condition is driven by hyperuricemia, often triggered by the rapid breakdown of cells during sudden weight loss or the consumption of foods high in purines. In an acute flare, the joint becomes erythematous, edematous, and exquisitely sensitive to any mechanical pressure or movement.

Rationale:

A. Encouraging active range of motion is contraindicated during an acute gouty flare. The presence of needle-like uric acid crystals within the joint space causes significant mechanical friction and synovial inflammation. Physical activity or manipulation of the joint during this phase will exacerbate pain and potentially increase tissue damage. The joint should be immobilized and protected until the inflammation subsides.

B. Avoiding the consumption of wine and beer is a critical dietary instruction. Alcohol, particularly beer, is high in purines and interferes with the renal excretion of uric acid, significantly increasing the risk of recurrent attacks. While coffee was once debated, current evidence suggests it may actually lower urate levels; however, the restriction of alcohol is a foundational and high-priority intervention for managing gout.

C. Substituting natural fruit juices for carbonated drinks may be counterproductive if the juices are high in fructose. High fructose intake is associated with increased uric acid production and can trigger gout flares just as effectively as some high-purine foods. The nurse should instead encourage increased water intake to facilitate the dilution and renal clearance of uric acid crystals from the body.

D. Using an electric heating pad is inappropriate for an acute gout attack. Heat promotes local vasodilation, which can worsen the existing inflammatory edema and intensify the throbbing pain. Instead, cold applications (ice packs) are generally recommended during the acute phase to provide an analgesic effect and reduce the localized inflammatory response in the affected ankle.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data After the nurse assesses the client, the healthcare provider (HCP) writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Correct Answer is ["A","D"]

Explanation

Correct Answer is B

Explanation

The nurse evaluates the client's concerns and plans which actions to take. Select which plan of care recommendations are indicated or not indicated at this time. Each row must only have one response option selected.

The mother of a 10-year-old who has sickle cell anemia expresses concern that her child will become addicted to pain medication if she follows the instructions on the prescription. Which information is most important for the nurse to provide?

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

A nurse who usually works on a step-down unit is moved to work a 12-hour shift on the critical care unit. Which client is best for the charge nurse to assign to this nurse?

Patient Data The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.