The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

Evaluate pupil reactions every shift

Assess temperature every 4 hours

Monitor for cyanosis

Check reflexes

Answer and Explanation

The Correct Answer is C

Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.

Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.

Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.

Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.

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Correct Answer is B

Explanation

Choice A reason: Petechiae are small red or purple spots caused by bleeding into the skin, typically associated with platelet disorders, and are not a direct indicator of SBP.

Choice B reason: Increased abdominal pain is a common symptom of SBP, as the condition causes inflammation and irritation of the peritoneum, which can lead to significant discomfort.

Choice C reason: Jaundice is a sign of liver dysfunction but is not specific to SBP. It results from high levels of bilirubin in the blood and can occur in various liver diseases.

Choice D reason: Blood in emesis (vomiting) may indicate gastrointestinal bleeding, which can be a complication of cirrhosis but is not specific to SBP.

A. "I can sit down to put on my pants and shoes." B. "I try to exercise every day and rest when I am tired." C. "I do not need to use my walker to go to the bathroom." D. "My son removed all the loose rugs from the house."

Correct Answer is C

Explanation

Choice A reason: The statement about being able to sit down to put on pants and shoes indicates that the client is implementing safety measures to prevent falls, which is a positive outcome of effective teaching.

Choice B reason: Exercising daily and resting when tired is an appropriate strategy for managing Parkinson's disease symptoms, suggesting that the client has understood the education provided.

Choice C reason: The statement about not needing a walker could indicate a lack of understanding of the importance of mobility aids in preventing falls, which is a concern for clients with Parkinson's disease.

Choice D reason: Removing loose rugs from the house is a preventive measure to reduce fall risk, indicating that the client and family have understood and applied the education.

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The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

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Naxlex Comprehensive Predictor Exams

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